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Pneumonia

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For other uses, see Pneumonia (disambiguation).

Pneumonia
Classification and external resources

A chest X-ray showing a very prominent

wedge shaped pneumonia in the right lung.
ICD-10 J12., J13., J14., J15., J16., J17.,
J18., P23.
ICD-9 480-486, 770.0
DiseasesDB 10166
eMedicine topic list
MeSH D011014

Pneumonia
 Infectious pneumonias
Bacterial pneumonia
Viral pneumonia
Fungal pneumonia
Parasitic pneumonia
Atypical pneumonia
Community-acquired
pneumonia
Healthcare-associated
pneumonia
Hospital-acquired
pneumonia
Ventilator-associated
pneumonia
Severe acute respiratory
syndrome
Pneumonias caused by
infectious or
noninfectious agents
Aspiration pneumonia
Lipid pneumonia
Eosinophilic pneumonia
Bronchiolitis obliterans
organizing pneumonia
Noninfectious pneumonia
Chemical pneumonia
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Pneumonia is an inflammatory condition of the lung.[1] It is often characterized
as including inflammation of the parenchyma of the lung (that is, the alveoli) and
abnormal alveolar filling with fluid (consolidation and exudation).[2]

The alveoli are microscopic air filled sacs in the lungs responsible for gas
exchange. Pneumonia can result from a variety of causes, including infection
with bacteria, viruses, fungi, or parasites, and chemical or physical injury to the
lungs. Its cause may also be officially described as unknown when infectious
causes have been excluded.
Typical symptoms associated with pneumonia include cough, chest pain, fever,
and difficulty in breathing. Diagnostic tools include x-rays and examination of the
sputum. Treatment depends on the cause of pneumonia; bacterial pneumonia is
treated with antibiotics.

Pneumonia is common, occurring in all age groups, and is a leading cause of

death among the young, the old, and the chronically ill.[3] Vaccines to prevent
certain types of pneumonia are available. The prognosis depends on the type of
pneumonia, the treatment, any complications, and the person's underlying
health.

Contents
[hide]
1 Classification
1.1 Clinical
1.1.1 Community-acquired
1.1.2 Hospital-acquired
1.1.3 Other types
1.2 Other
2 Signs and symptoms
3 Cause
3.1 Viruses
3.2 Bacteria
3.3 Fungi
3.4 Parasites
3.5 Idiopathic
4 Diagnosis
4.1 Investigations
4.2 Combining findings
4.3 Differential diagnosis
4.4 Appearance on X ray
5 Prevention
6 Treatment
6.1 Bacterial
6.2 Viral
6.3 Aspiration
7 Complications
7.1 Respiratory and circulatory
failure
7.2 Pleural effusion, empyema, and
abscess
8 Prognosis
8.1 Clinical prediction rules
9 Epidemiology
10 History
11 Society and culture
12 See also
13 References
Classification

This section needs additional citations for verification.

Please help improve this article by adding reliable references.
Unsourced material may be challenged and removed. (August 2009)
Pneumonias can be classified in several ways. The primary system of
classification is the combined clinical classification, which combines factors such
as age, risk factors for certain microorganisms, the presence of underlying lung
disease or systemic disease, and whether the person has recently been
hospitalized.

Other classifications include according to the anatomic changes that can be

found in the lungs during autopsies, based on the microbial cause, and a
radiological classification.

Clinical

Traditionally, clinicians have classified pneumonia by clinical characteristics,

dividing them into "acute" (less than three weeks duration) and "chronic"
pneumonias. This is useful because chronic pneumonias tend to be either non-
infectious, or mycobacterial, fungal, or mixed bacterial infections caused by
airway obstruction. Acute pneumonias are further divided into the classic
bacterial bronchopneumonias (such as Streptococcus pneumoniae), the atypical
pneumonias (such as the interstitial pneumonitis of Mycoplasma pneumoniae or
Chlamydia pneumoniae), and the aspiration pneumonia syndromes.

Chronic pneumonias, on the other hand, mainly include those of Nocardia,

Actinomyces and Blastomyces dermatitidis, as well as the granulomatous
pneumonias (Mycobacterium tuberculosis and atypical mycobacteria,
Histoplasma capsulatum and Coccidioides immitis).[4]

The combined clinical classification, now the most commonly used classification
scheme, attempts to identify a person's risk factors when he or she first comes
to medical attention. The advantage of this classification scheme over previous
systems is that it can help guide the selection of appropriate initial treatments
even before the microbiologic cause of the pneumonia is known. There are two
broad categories of pneumonia in this scheme: community-acquired pneumonia
and hospital-acquired pneumonia. A recently introduced type of healthcare-
associated pneumonia (in patients living outside the hospital who have recently
been in close contact with the health care system) lies between these two
categories.

Community-acquired

Main article: Community-acquired pneumonia

Community-acquired pneumonia (CAP) is infectious pneumonia in a person who

has not recently been hospitalized. CAP is the most common type of pneumonia.
The most common causes of CAP vary depending on a person's age, but they
include Streptococcus pneumoniae, viruses, the atypical bacteria, and
Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most
common cause of community-acquired pneumonia worldwide. Gram-negative
bacteria cause CAP in certain at-risk populations. CAP is the fourth most common
cause of death in the United Kingdom and the sixth in the United States. The
term "walking pneumonia" has been used to describe a type of community-
acquired pneumonia of less severity (because the sufferer can continue to "walk"
rather than require hospitalization).[5] Walking pneumonia is usually caused by
the atypical bacterium, Mycoplasma pneumoniae.[6]

Hospital-acquired

Main article: Hospital-acquired pneumonia

Hospital-acquired pneumonia, also called nosocomial pneumonia, is pneumonia

acquired during or after hospitalization for another illness or procedure with
onset at least 72 hrs after admission. The causes, microbiology, treatment and
prognosis are different from those of community-acquired pneumonia. Up to 5%
of patients admitted to a hospital for other causes subsequently develop
pneumonia. Hospitalized patients may have many risk factors for pneumonia,
including mechanical ventilation, prolonged malnutrition, underlying heart and
lung diseases, decreased amounts of stomach acid, and immune disturbances.
Additionally, the microorganisms a person is exposed to in a hospital are often
different from those at home. Hospital-acquired microorganisms may include
resistant bacteria such as MRSA, Pseudomonas, Enterobacter, and Serratia.
Because individuals with hospital-acquired pneumonia usually have underlying
illnesses and are exposed to more dangerous bacteria, it tends to be more
deadly than community-acquired pneumonia. Ventilator-associated pneumonia
(VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia which
occurs after at least 48 hours of intubation and mechanical ventilation.

Other types

Bronchiolitis obliterans organizing pneumonia (BOOP)

BOOP is caused by inflammation of the small airways of the lungs. It is also

known as cryptogenic organizing pneumonitis (COP).

Eosinophilic pneumonia

Eosinophilic pneumonia is invasion of the lung by eosinophils, a particular kind of

white blood cell. Eosinophilic pneumonia often occurs in response to infection
with a parasite or after exposure to certain types of environmental factors.

Chemical pneumonia

Chemical pneumonia (usually called chemical pneumonitis) is caused by

chemical toxicants such as pesticides, which may enter the body by inhalation or
by skin contact. When the toxic substance is an oil, the pneumonia may be called
lipoid pneumonia.
Aspiration pneumonia

Aspiration pneumonia (or aspiration pneumonitis) is caused by aspirating foreign

objects which are usually oral or gastric contents, either while eating, or after
reflux or vomiting which results in bronchopneumonia. The resulting lung
inflammation is not an infection but can contribute to one, since the material
aspirated may contain anaerobic bacteria or other unusual causes of pneumonia.
Aspiration is a leading cause of death among hospital and nursing home
patients, since they often cannot adequately protect their airways and may have
otherwise impaired defenses.

Dust pneumonia

Dust pneumonia describes disorders caused by excessive exposure to dust

storms, particularly during the Dust Bowl in the United States. With dust
pneumonia, dust settles all the way into the alveoli of the lungs, stopping the
cilia from moving and preventing the lungs from ever clearing themselves.

Necrotizing pneumonia, although overlapping with many other classifications,

includes pneumonias that cause substantial necrosis of lung cells, and
sometimes even lung abscess. Implicated bacteria are extremely commonly
anaerobic bacteria, with or without additional facultatively anaerobic ones like
Staphylococcus aureus, Klebsiella pneumoniae and Streptococcus pyogenes.[4]
Type 3 pneumococcus is uncommonly implicated.[4]

Opportunistic pneumonia includes those that frequently strike

immunocompromised victims. Main pathogens are cytomegalovirus,
Pneumocystis jiroveci, Mycobacterium avium-intracellulare, invasive
aspergillosis, invasive candidiasis, as well as the "usual bacteria" that strike
immunocompetent people as well.[4]

Double pneumonia is a historical term for acute lung injury (ALI) or acute
respiratory distress syndrome (ARDS).[7] However, the term was, and is used
still, especially by lay people, to denote pneumonia affecting both lungs.
Accordingly, the term 'double pneumonia' is more likely to be used to describe
bilateral pneumonia than it is ALI or ARDS.

Severe acute respiratory syndrome (SARS)

SARS is a highly contagious and deadly type of pneumonia which first occurred in
2002 after initial outbreaks in China. SARS is caused by the SARS coronavirus, a
previously unknown pathogen. Last recorded occurrence was in 2003.

Other

Initial descriptions of pneumonia focused on the anatomic or pathologic

appearance of the lung, either by direct inspection at autopsy or by its
appearance under a microscope.
A lobar pneumonia is an infection that only involves a single lobe, or section, of a
lung. Lobar pneumonia is often due to Streptococcus pneumoniae (though
Klebsiella pneumoniae is also possible.)[8]

Multilobar pneumonia involves more than one lobe, and it often causes a more
severe illness.

Bronchial pneumonia affects the lungs in patches around the tubes (bronchi or
bronchioles).

Interstitial pneumonia involves the areas in between the alveoli, and it may be
called "interstitial pneumonitis." It is more likely to be caused by viruses or by
atypical bacteria.

The discovery of x-rays made it possible to determine the anatomic type of

pneumonia without direct examination of the lungs at autopsy and led to the
development of a radiological classification. Early investigators distinguished
between typical lobar pneumonia and atypical (e.g. Chlamydophila) or viral
pneumonia using the location, distribution, and appearance of the opacities they
saw on chest x-rays. Certain x-ray findings can be used to help predict the
course of illness, although it is not possible to clearly determine the
microbiologic cause of a pneumonia with x-rays alone.

With the advent of modern microbiology, classification based upon the causative
microorganism became possible. Determining which microorganism is causing
an individual's pneumonia is an important step in deciding treatment type and
length. Sputum cultures, blood cultures, tests on respiratory secretions, and
specific blood tests are used to determine the microbiologic classification.
Because such laboratory testing typically takes several days, microbiologic
classification is usually not possible at the time of initial diagnosis.

Signs and symptoms

Main symptoms of infectious pneumonia

 Crackles

Crackles heard in the lungs of a person with

pneumonia using a stethoscope.

Problems listening to this file? See media help.

People with infectious pneumonia often have a cough producing greenish or
yellow sputum, or phlegm and a high fever that may be accompanied by shaking
chills. Shortness of breath is also common, as is pleuritic chest pain, a sharp or
stabbing pain, either experienced during deep breaths or coughs or worsened by
them. People with pneumonia may cough up blood, experience headaches, or
develop sweaty and clammy skin. Other possible symptoms are loss of appetite,
fatigue, blueness of the skin, nausea, vomiting, mood swings, and joint pains or
muscle aches. Less common forms of pneumonia can cause other symptoms; for
instance, pneumonia caused by Legionella may cause abdominal pain and
diarrhea, while pneumonia caused by tuberculosis or Pneumocystis may cause
only weight loss and night sweats. In elderly people, manifestations of
pneumonia are seldom typical. They may develop a new or worsening confusion
(delirium) or may experience unsteadiness, leading to falls. Infants with
pneumonia may have many of the symptoms above, but in many cases they are
simply sleepy or have a decreased appetite.[9]

Pneumonia fills the lung's alveoli with fluid, keeping oxygen from reaching the
bloodstream. The alveolus on the left is normal, while the alveolus on the right is
full of fluid from pneumonia.

Symptoms of pneumonia need immediate medical evaluation. Physical

examination by a health care provider may reveal fever or sometimes low body
temperature, an increased respiratory rate, low blood pressure, a high heart
rate, or a low oxygen saturation, which is the amount of oxygen in the blood as
indicated by either pulse oximetry or blood gas analysis. People who are
struggling to breathe, who are confused, or who have cyanosis (blue-tinged skin)
require immediate attention.

Findings from physical examination of the lungs may be normal, but often show
decreased expansion of the chest on the affected side, bronchial breathing on
auscultation with a stethoscope (harsher sounds from the larger airways
transmitted through the inflamed and consolidated lung), and rales (or crackles)
heard over the affected area during inspiration. Percussion may be dulled over
the affected lung, but increased rather than decreased vocal resonance (which
distinguishes it from a pleural effusion).[9] While these signs are relevant, they
are insufficient to diagnose or rule out a pneumonia; moreover, in studies it has
been shown that two doctors can arrive at different findings on the same patient.
[10][11]

Cause

This section needs additional citations for verification.

Please help improve this article by adding reliable references.
Unsourced material may be challenged and removed. (August 2009)
Upper panel shows a normal lung under a microscope. The white spaces are
alveoli that contain air. Lower panel shows a lung with pneumonia under a
microscope. The alveoli are filled with inflammation and debris.

Pneumonia can be caused by microorganisms, irritants and unknown causes.

When pneumonias are grouped this way, infectious causes are the most common
type.

The symptoms of infectious pneumonia are caused by the invasion of the lungs
by microorganisms and by the immune system's response to the infection.
Although more than one hundred strains of microorganism can cause
pneumonia, only a few are responsible for most cases. The most common causes
of pneumonia are viruses and bacteria. Less common causes of infectious
pneumonia are fungi and parasites.

Viruses

Main article: Viral pneumonia

Viruses have been found to account for between 18—28% of pneumonia in a few
limited studies.[12] Viruses invade cells in order to reproduce. Typically, a virus
reaches the lungs when airborne droplets are inhaled through the mouth and
nose. Once in the lungs, the virus invades the cells lining the airways and alveoli.
This invasion often leads to cell death, either when the virus directly kills the
cells, or through a type of cell controlled self-destruction called apoptosis. When
the immune system responds to the viral infection, even more lung damage
occurs. White blood cells, mainly lymphocytes, activate certain chemical
cytokines which 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 bacterial infections; for which reason bacterial pneumonia may complicate
viral pneumonia.[12]

Viral pneumonia is commonly caused by viruses such as influenza virus,

respiratory syncytial virus (RSV), adenovirus, and parainfluenza.[12] Herpes
simplex virus is a rare cause of pneumonia except in newborns. People with
weakened immune systems are also at risk of pneumonia caused by
cytomegalovirus (CMV).

Bacteria

Main article: Bacterial pneumonia

The bacterium Streptococcus pneumoniae, a common cause of pneumonia,
photographed through an electron microscope.

Bacteria are the most common cause of community acquired pneumonia with
Streptococcus pneumoniae the most commonly isolated bacteria.[13] Another
important Gram-positive cause of pneumonia is Staphylococcus aureus, with
Streptococcus agalactiae being an important cause of pneumonia in newborn
babies. Gram-negative bacteria cause pneumonia less frequently than gram-
positive bacteria. Some of the gram-negative bacteria that cause pneumonia
include Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli,
Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in
the stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical"
bacteria which cause pneumonia include Chlamydophila pneumoniae,
Mycoplasma pneumoniae, and Legionella pneumophila.

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.

Fungi

Main article: Fungal pneumonia

Fungal pneumonia is uncommon, but it may occur in individuals with immune

system problems due to AIDS, immunosuppresive 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 in the southwestern United States.

Parasites

Main article: Parasitic pneumonia

A variety of parasites can affect the lungs. These parasites typically enter the
body through the skin or by being swallowed. Once inside, they travel to the
lungs, usually through the blood. There, as in other cases 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 pneumonias (IIP) are a class of diffuse lung diseases. In

some types of IIP, e.g. some types of usual interstitial pneumonia, the cause,
indeed, is unknown or idiopathic. In some types of IIP the cause of the
pneumonia is known, e.g. desquamative interstitial pneumonia is caused by
smoking, and the name is a misnomer.

Diagnosis
Pneumonia as seen on chest x-ray. A: Normal chest x-ray. B: Abnormal chest x-
ray with shadowing from pneumonia in the right lung (white area, left side of
image).

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

If pneumonia is suspected on the basis of a patient's symptoms and findings

from physical examination, further investigations are needed to confirm the
diagnosis. Information from a chest X-ray and blood tests are helpful, and
sputum cultures in some cases. The chest X-ray is typically used for diagnosis in
hospitals and some clinics with X-ray facilities. However, in a community setting
(general practice), pneumonia is usually diagnosed based on symptoms and
physical examination alone.[citation needed] Diagnosing pneumonia can be
difficult in some people, especially those who have other illnesses. Occasionally a
chest CT scan or other tests may be needed to distinguish pneumonia from other
illnesses.

Investigations

An important test for pneumonia in unclear situations is a chest x-ray. Chest x-

rays can reveal areas of opacity (seen as white) which represent consolidation.
Pneumonia is not always seen on x-rays, either because the disease is only in its
initial stages, or because it involves a part of the lung not easily seen by x-ray. In
some cases, chest CT (computed tomography) can reveal pneumonia that is not
seen on chest x-ray. X-rays can be misleading, because other problems, like lung
scarring and congestive heart failure, can mimic pneumonia on x-ray.[14] Chest
x-rays are also used to evaluate for complications of pneumonia (see below.)

If antibiotics fail to improve the patient's health, or if the health care provider has
concerns about the diagnosis, a culture of the person's sputum may be
requested. Sputum cultures generally take at least two to three days, so they are
mainly used to confirm that the infection is sensitive to an antibiotic that has
already been started. A blood sample may similarly be cultured to look for
bacteria in the blood. Any bacteria identified are then tested to see which
antibiotics will be most effective.
A complete blood count may show a high white blood cell count, indicating the
presence of an infection or inflammation. In some people with immune system
problems, the white blood cell count may appear deceptively normal. Blood tests
may be used to evaluate kidney function (important when prescribing certain
antibiotics) or to look for low blood sodium. Low blood sodium in pneumonia is
thought to be due to extra anti-diuretic hormone produced when the lungs are
diseased (SIADH). Specific blood serology tests for other bacteria (Mycoplasma,
Legionella and Chlamydophila) and a urine test for Legionella antigen are
available. Respiratory secretions can also be tested for the presence of viruses
such as influenza, respiratory syncytial virus, and adenovirus. Liver function tests
should be carried out to test for damage caused by sepsis.[9]

Combining findings

One study created a prediction rule that found the five following signs best
predicted infiltrates on the chest radiograph of 1134 patients presenting to an
emergency room:[15]

Fever > 37.8 °C (100.0 °F)

Pulse > 100 beats/min

Rales/crackles

Decreased breath sounds

Absence of asthma

The probability of an infiltrate in two separate validations was based on the

number of findings:

5 findings – 84% to 91% probability

4 findings – 58% to 85%

3 findings – 35% to 51%

2 findings – 14% to 24%

1 findings – 5% to 9%

0 findings – 2% to 3%

A subsequent study[16] comparing four prediction rules to physician judgment

found that two rules, the one above[15] and also[17] were more accurate than
physician judgment because of the increased specificity of the prediction rules.

Differential diagnosis

Several diseases and/or conditions can present with similar clinical features to
pneumonia. Chronic obstructive pulmonary disease (COPD) or asthma can
present with a polyphonic wheeze, similar to that of pneumonia. Pulmonary
edema can be mistaken for pneumonia (and vice versa), especially in the elderly,
due to its similar symptoms and signs. Other diseases to be taken into
consideration include bronchiectasis, lung cancer and pulmonary emboli.[9]

Appearance on X ray

AP CXR showing left

lower lobe pneumonia AP CXR showing
associated with a small right lower lobe
Normal AP CXR Normal lateral CXR left sided pleural pneumonia
effusion

A lateral CXR AP CXR showing Right upper lobe

showing right pneumonia of the pneumonia as marked
lower lobe lingula of the left by the circle.
pneumonia lung
Prevention

There are several ways to prevent infectious pneumonia. Appropriately treating

underlying illnesses (such as AIDS) can decrease a person's risk of pneumonia.
Smoking cessation is important not only because it helps to limit lung damage,
but also because cigarette smoke interferes with many of the body's natural
defenses against pneumonia.

Research shows that there are several ways to prevent pneumonia in newborn
infants. Testing pregnant women for Group B Streptococcus and Chlamydia
trachomatis, and then 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.

Vaccination is important for preventing pneumonia in both children and adults.

Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in
the first year of life have greatly reduced the role these bacteria play in causing
pneumonia in children. Vaccinating children against Streptococcus pneumoniae
has also led to a decreased incidence of these infections in adults because many
adults acquire infections from children. Hib vaccine is now widely used around
the globe. The childhood pneumococcal vaccine is still as of 2009 predominantly
used in high-income countries, though this is changing. In 2009, Rwanda became
the first low-income country to introduce pneumococcal conjugate vaccine into
their national immunization program.[18]

A vaccine against Streptococcus pneumoniae is also available for adults. In the

U.S., it is currently recommended for all healthy individuals older than 65 and
any adults with emphysema, congestive heart failure, diabetes mellitus, cirrhosis
of the liver, alcoholism, cerebrospinal fluid leaks, or those who do not have a
spleen. A repeat vaccination may also be required after five or ten years.[19]

Influenza vaccines should be given yearly to the same individuals who receive
vaccination against Streptococcus pneumoniae. In addition, health care workers,
nursing home residents, and pregnant women should receive the vaccine.[20]
When an influenza outbreak is occurring, medications such as amantadine,
rimantadine, zanamivir, and oseltamivir can help prevent influenza.[21][22]

Treatment

In the United States more than 80% of cases of community acquired pneumonia
are treated without hospitalization.[13] Typically, oral antibiotics, rest, fluids, and
home care are sufficient for complete resolution. However, people who are
having trouble breathing, with other medical problems, and the elderly may need
greater care. If the symptoms get worse, the pneumonia does not improve with
home treatment, or complications occur, then hospitalization may be
recommended. Over the counter cough medicine has not been found to be
helpful in pneumonia.[23]

Bacterial

Antibiotics improve outcomes in those with bacterial pneumonia.[24] Initially

antibiotic choice depends on the characteristics of the person affected such as
age, underlying health, and location the infection was acquired.

In the UK empiric treatment is usually with amoxicillin, erythromycin, or

azithromycin for community-acquired pneumonia.[25] In North America, where
the "atypical" forms of community-acquired pneumonia are becoming more
common, macrolides (such as azithromycin), and doxycycline have displaced
amoxicillin as first-line outpatient treatment for community-acquired pneumonia.
[13][26] The use of fluoroquinolones in uncomplicated cases is discouraged due
to concerns of side effects and resistance.[13] The duration of treatment has
traditionally been seven to ten days, but there is increasing evidence that short
courses (three to five days) are equivalent.[27] Antibiotics recommended for
hospital-acquired pneumonia include third- and fourth-generation
cephalosporins, carbapenems, fluoroquinolones, aminoglycosides, and
vancomycin.[28] These antibiotics are often given intravenously and may be
used in combination.

Viral

No specific treatments exist for most types of viral pneumonia including SARS
coronavirus, adenovirus, hantavirus, and parainfluenza virus with the exception
of influenza A and influenza B. Influenza A may be treated with rimantadine or
amantadine while influenza A or B may be treated with oseltamivir or zanamivir.
These are beneficial only if they are started within 48 hours of the onset of
symptoms. Many strains of H5N1 influenza A, also known as avian influenza or
"bird flu," have shown resistance to rimantadine and amantadine.

Aspiration

There is no evidence to support the use of antibiotics in chemical pneumonitis

without bacterial superinfection. If infection is present in aspiration pneumonia,
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 beta-lactam antibiotic and metronidazole, or an
aminoglycoside.[29] Corticosteroids are commonly used in aspiration
pneumonia, but there is no evidence to support their use either.[29]

Complications

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

Because pneumonia affects the lungs, often people with pneumonia have
difficulty breathing, and it may not be possible for them to breathe well enough
to stay alive without support. 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, create a need for mechanical ventilation.
Pleural effusion. Chest x-ray showing a pleural effusion. The A arrow indicates
"fluid layering" in the right chest. The B arrow indicates the width of the right
lung. The volume of useful lung is reduced because of the collection of fluid
around the lung.

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 from
dropping too low. Sepsis can cause liver, kidney, and heart damage, among
other problems, and it often causes death.

Pleural effusion, empyema, and abscess

Occasionally, microorganisms infecting the lung will cause fluid (a pleural

effusion) to build up in the space that surrounds the lung (the pleural cavity). If
the microorganisms themselves are present in the pleural cavity, the fluid
collection is called an empyema. When pleural fluid is present in a person with
pneumonia, the fluid can often be collected with a needle (thoracentesis) and
examined. Depending on the results of this examination, complete drainage of
the fluid may be necessary, often requiring a chest tube. In severe cases of
empyema, surgery may be needed. If the fluid is not drained, the infection may
persist, because antibiotics do not penetrate well into the pleural cavity.

Rarely, bacteria in the lung will form a pocket of infected fluid called an 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.

Prognosis

With treatment, most types of bacterial pneumonia can be cleared within two to
four weeks.[30] Viral pneumonia may last longer, and mycoplasmal pneumonia
may take four to six weeks to resolve completely.[30] The eventual outcome of
an episode of pneumonia depends on how ill the person is when he or she is first
diagnosed.[30]

In the United States, about one of every twenty people with pneumococcal
pneumonia die. In cases where the pneumonia progresses to blood poisoning
(bacteremia), just over 20% of sufferers die.[31]

The death rate (or mortality) also depends on the underlying cause of the
pneumonia. Pneumonia caused by Mycoplasma, for instance, is associated with
little mortality. However, about half of the people who develop methicillin-
resistant Staphylococcus aureus (MRSA) pneumonia while on a ventilator will die.
[32] In regions of the world without advanced health care systems, pneumonia is
even deadlier. Limited access to clinics and hospitals, limited access to x-rays,
limited antibiotic choices, and inability to treat underlying conditions inevitably
leads 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 coutries.[33]

Adenovirus can cause severe necrotizing pneumonia in which all or part of a lung
has increased translucency radiographically, which is called Swyer-James
Syndrome.[34] 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.[34]

Clinical prediction rules

Clinical prediction rules have been developed to more objectively prognosticate

outcomes in pneumonia. These rules can be helpful in deciding whether or not to
hospitalize the person.

Pneumonia severity index (or PORT Score)[35] – online calculator

CURB-65 score, which takes into account the severity of symptoms, any
underlying diseases, and age[36] – online calculator

Epidemiology

Pneumonia is a common illness in all parts of the world. It is a major cause of

death among all age groups and is the leading cause of death in children in low
income countries.[24] In children, 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.[37] Over two million children under five die
each year worldwide and it is estimated that up to 1 million of these (vaccine
preventable) deaths are caused by the bacteria Streptococcus pneumoniae, and
over 90% of these deaths take place in developing countries.[38] Mortality from
pneumonia generally decreases with age until late adulthood with increased
mortality in the elderly.

In the United Kingdom, the annual incidence of pneumonia is approximately 6

cases for every 1000 people for the 18–39 age group. For those over 75 years of
age, this rises to 75 cases for every 1000 people. Roughly 20–40% of individuals
who contract pneumonia require hospital admission of which between 5–10% are
admitted to a critical care unit. The mortality rate in the UK is around 5–10%.[9]
In the United States community acquired pneumonia affects 5.6 million people a
year making it the 6th leading cause of death.[13]

More cases of pneumonia occur during the winter months than during other
times of the year. Pneumonia occurs more commonly in males than females, and
more often in Blacks than Caucasians due to differences in synthesizing Vitamin
D from sunlight. Individuals with underlying illnesses such as Alzheimer's
disease, cystic fibrosis, emphysema, tobacco smoking, alcoholism, or immune
system problems are at increased risk for pneumonia.[39] These individuals are
also more likely to have repeated episodes of pneumonia. People who are
hospitalized for any reason are also at high risk for pneumonia.

History

Hippocrates, the ancient Greek physician known as the "father of medicine"

WPA poster, 1936/1937

The symptoms of pneumonia were described by Hippocrates (c. 460 BC – 370

BC):
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.[40]

However, Hippocrates referred to pneumonia as a disease "named by the

ancients." He also reported the results of surgical drainage of empyemas.
Maimonides (1138–1204 AD) observed "The basic symptoms which occur in
pneumonia and which are never lacking are as follows: acute fever, sticking
[pleuritic] pain in the side, short rapid breaths, serrated pulse and cough."[41]
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.[42] Initial work identifying the two common bacterial
causes Streptococcus pneumoniae and Klebsiella pneumoniae was performed by
Carl Friedländer[43] and Albert Fränkel[44] in 1882 and 1884, respectively.
Friedländer's initial work introduced the Gram stain, a fundamental laboratory
test still used 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.
[45]

Sir William Osler, known as "the father of modern medicine," appreciated the
morbidity and mortality of 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 his time. (The phrase was originally coined by John Bunyan with regard
to consumption, or tuberculosis.[46]) However, several key 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.[47] Vaccination against Streptococcus pneumoniae in
adults began in 1977 and in children began in 2000, resulting in a similar
decline.[48]

Society and culture

Because of the very high burden of disease in developing countries and because
of a relatively low awareness of the disease in industrialized countries, the global
health community has declared November 2 to be World Pneumonia Day, a day
for concerned citizens and policy makers to take action against the disease.[1]
See also

List of pneumonia victims

References

^ pneumonia at eMedicine Dictionary

^ pneumonia at Dorland's Medical Dictionary

^ "Causes of death in neonates and children under five in the world (2004)".
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^ a b c d Table 13-7 in: Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul
K.; Fausto, Nelson (2007). Robbins Basic Pathology (8th ed.). Philadelphia:
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^ "UpToDate Inc.". http://www.uptodate.com/online/content/topic.do?

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^ Krause DC, Balish MF (February 2004). "Cellular engineering in a minimal

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^ PneumoADIP. Vaccine Introduction: Rwanda.

^ Butler JC, Breiman RF, Campbell JF, Lipman HB, Broome CV, Facklam RR
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^ "Prevention and control of influenza: recommendations of the Advisory

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^ Jefferson T, Deeks JJ, Demicheli V, Rivetti D, Rudin M (2004). "Amantadine and

rimantadine for preventing and treating influenza A in adults". Cochrane
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^ Hayden FG, Atmar RL, Schilling M, et al. (October 1999). "Use of the selective
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^ "2004 Pneumonia Guideline – Synopsis" (PDF). p. iv5. http://www.brit-

thoracic.org.uk/Portals/0/Clinical
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^ Lutfiyya MN, Henley E, Chang LF, Reyburn SW (February 2006). "Diagnosis and
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^ Scalera NM, File TM (April 2007). "How long should we treat community-
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^ American Thoracic Society; Infectious Diseases Society of America (February

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^ a b c Pneumonia, Bacterial at eMedicine, specifically, "The chest radiograph

usually clears within 4 weeks in patients younger than 50 years without
underlying pulmonary disease". Symptoms are often resolved within 1–2 weeks.]

^ Mufson, MA; RJ Stanek (1999-07-26). "Bacteremic pneumococcal pneumonia in

one American City: a 20-year longitudinal study, 1978–1997". Am J Med
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^ Combes A, Luyt CE, Fagon JY, et al. (October 2004). "Impact of methicillin
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^ World Health Organization. Acute Respiratory Infections: Streptococcus

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^ a b Kliegman, Robert; Richard M Kliegman (2006). Nelson essentials of

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^ Fine MJ, Auble TE, Yealy DM, et al. (January 1997). "A prediction rule to identify
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^ Almirall J, Bolíbar I, Balanzó X, González CA (February 1999). "Risk factors for

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^ Hippocrates On Acute Diseases wikisource link

^ Maimonides, Fusul Musa ("Pirkei Moshe").

^ Klebs E (1875-12-10). "Beiträge zur Kenntniss der pathogenen

Schistomyceten. VII Die Monadinen". Arch. Exptl. Pathol. Parmakol. 4 (5/6): 40–
488.

^ Friedländer C (1882-02-04). "Über die Schizomyceten bei der acuten fibrösen

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^ Fraenkel A (1884-04-21). "Über die genuine Pneumonie, Verhandlungen des

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^ Gram C (1884-03-15). "Über die isolierte Färbung der Schizomyceten in

Schnitt- und Trocken-präparaten". Fortschr. Med 2 (6): 185–9.

^ William Osler, Thomas McCrae (1920). The principles and practice of medicine:
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^ Adams WG, Deaver KA, Cochi SL, et al. (January 1993). "Decline of childhood
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PMID 12724479.

[show]
v•d•e
Pathology: Medical conditions and ICD code

(Disease / Disorder / Illness, Syndrome / Sequence, Symptom / Sign, Injury,

etc.)

Infectious disease/Infection: Bacterial disease (G+, G-) · Virus

(A/B, 001-
disease · Parasitic disease (Protozoan infection, Helminthiasis,
139)
Ectoparasitic infestation) · Mycosis · Zoonosis

Cancer (C00-D48, 140-239) Tumor

Myeloid hematologic (D50-D77,

(C/D, Anemia · Coagulopathy
280-289)
140-239 &
279-289)
Immunodeficiency ·
Lymphoid immune (D80-D89,
Immunoproliferative disorder ·
279)
Hypersensitivity

(E, 240- Endocrine disease · Nutrition disorder · Inborn error of

278) metabolism

(F, 290-
Mental disorder
319)

(G, 320-
Nervous system disease (CNS, PNS) · Neuromuscular disease
359)

(H, 360-
Eye disease · Ear disease
389)

(I, 390-
Cardiovascular disease (Heart disease, Vascular disease)
459)

(J, 460- Respiratory disease (Obstructive lung disease, Restrictive lung

519) disease, Pneumonia)

(K, 520- Stomatognathic disease (Tooth disease) · Digestive disease

579) (Esophageal, Stomach, Enteropathy, Liver, Pancreatic)

(L, 680- Skin disease · skin appendages (Nail disease, Hair disease,
709) Sweat gland disease)
(M, 710- Musculoskeletal disorders: Myopathy · Arthropathy ·
739) Osteochondropathy (Osteopathy, Chondropathy)

(N, 580- Urologic disease (Nephropathy, Urinary bladder disease) · Male

629) genital disease · Breast disease · Female genital disease

(O, 630- Complications of pregnancy · Obstetric labor complication ·

679) Puerperal disorder

(P, 760-
Fetal disease
779)

(Q, 740-
Congenital disorder (Congenital abnormality)
759)

(R, 780-
Syndromes · Medical signs (Eponymous)
799)

(S/T, 800- Bone fracture · Joint dislocation · Sprain · Strain · Subluxation ·

999) Head injury · Chest trauma · Poisoning

[show]
v•d•e
Pathology of respiratory system (J, 460–519), respiratory diseases

sinuses: Sinusitis
nose: Rhinitis (Vasomotor rhinitis, Atrophic rhinitis,
Hay fever) · Nasal polyp · Rhinorrhea · nasal septum
Hea
(Nasal septum deviation, Nasal septum perforation,
d
Nasal septal hematoma)
tonsil: Tonsillitis · Adenoid hypertrophy · Peritonsillar
abscess
Upper RT
(including URTIs,
pharynx: Laryngopharyngeal reflux (LPR) · Pharyngitis
Common cold)
(Strep throat) · Retropharyngeal abscess
larynx: Croup · Laryngitis · Laryngopharyngeal reflux
Nec (LPR) · Laryngospasm
k vocal folds: Laryngopharyngeal reflux (LPR) · Vocal
fold nodule · Vocal cord paresis
epiglottis: Epiglottitis
trachea: Tracheitis · Tracheal stenosis

Lower RT/lung Bronchial/ acute: Acute bronchitis

disease obstructive chronic: COPD (Chronic bronchitis, Acute
(including LRTIs) exacerbations of chronic bronchitis, Acute
 exacerbation of COPD, Emphysema, Diffuse
panbronchiolitis) · Asthma (Status
asthmaticus, Aspirin-induced) · Bronchiectasis
unspecified: Bronchitis · Bronchiolitis
(Bronchiolitis obliterans)

Pneumoconiosis (Asbestosis,
Baritosis, Bauxite fibrosis,
Berylliosis, Caplan's syndrome,
External
Chalicosis, Coalworker's
agents/
pneumoconiosis, Siderosis,
occupational
Silicosis, Talcosis, Byssinosis)
lung disease
Hypersensitivity pneumonitis
(Bagassosis, Bird fancier's lung,
Interstitial/ Farmer's lung)
restrictive
(fibrosis) ARDS · Pulmonary edema ·
Löffler's syndrome/Eosinophilic
pneumonia · Respiratory
hypersensitivity (Allergic
Other bronchopulmonary aspergillosis)

Hamman-Rich syndrome ·
Idiopathic pulmonary fibrosis ·
Sarcoidosis

Obstructive Viral · Bacterial

or (Pneumococcal,
restrictive Klebsiella) / Atypical
bacterial (Mycoplasma,
Legionnaires' disease,
By pathogen Chlamydiae) · Fungal
(Pneumocystis) ·
Parasitic · noninfectious
(Chemical/Mendelson's
Pneumoni
syndrome,
a/
Aspiration/Lipid)
pneumoni
tis
Community-acquired ·
By
Healthcare-associated ·
vector/route
Hospital-acquired

By
Broncho- · Lobar
distribution

UIP · DIP · BOOP-COP ·

IIP
NSIP · RB
 Atelectasis · circulatory (Pulmonary
Other hypertension, Pulmonary
embolism) · Lung abscess

Pleuritis/pleurisy
Pneumothorax/Hemopneumothorax
(Tension pneumothorax)
Pleural disease Pleural effusion: Hemothorax ·
Pleural cavity/ Hydrothorax · Chylothorax ·
mediastinum Empyema/pyothorax · Malignant
Fibrothorax

Mediastinal
Mediastinitis · Mediastinal emphysema
disease

Respiratory failure · Influenza · SARS · Idiopathic

Other/general pulmonary haemosiderosis · Pulmonary alveolar
proteinosis

M: RES anat(n, x, l, noco(c)/cong/tumr, proc,

c)/phys/devp sysi/epon, injr drug(R1/2/3/5/6/7)

[show]
v•d•e
Common cold

Rhinovirus - Coronavirus - Human parainfluenza viruses - Human

Viruses respiratory syncytial virus - Adenovirus - Enterovirus -
Metapneumovirus

Pharyngitis - Rhinorrhea - Nasal congestion - Sneezing - Cough -

Symptoms Muscle aches - Fatigue - Malaise - Headache - Weakness - Loss
of appetite

Complicati Acute bronchitis - Bronchiolitis - Croup - Pneumonia - Sinusitis -

ons Otitis media - Strep throat

Antiviral
Pleconaril (experimental)
drugs

M: RES anat(n, x, l, noco(c)/cong/tumr, proc,

c)/phys/devp sysi/epon, injr drug(R1/2/3/5/6/7)
Retrieved from "http://en.wikipedia.org/wiki/Pneumonia"
Categories: Infectious diseases | Pneumonia | Pulmonology | Respiratory and
cardiovascular disorders specific to the perinatal period

Hidden categories: All articles with dead external links | Articles with dead
external links from July 2010 | Articles needing additional references from August
2009 | All articles needing additional references | Articles with hAudio
microformats | All articles with unsourced statements | Articles with unsourced
statements from March 2009

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