Pneumonia is an inflammatory condition of the lungespecially affecting the microscopic air sacs (alveoli) associated with fever, chest

symptoms, and a lack of air space (consolidation) on a chest X-ray.[1][2] Pneumonia is typically caused by an infection but there are a number of other causes.[1] Infectious agents include: bacteria, viruses, fungi, and parasites.[3] Typical symptoms include cough, chest pain, fever, and difficulty breathing.[4] Diagnostic tools include x-rays and examination of the sputum. Vaccines to prevent certain types of pneumonia are available. Treatment depends on the underlying cause with presumed bacterial pneumonia being treated with antibiotics. Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death", the advent of antibiotic therapy and vaccines in the 20th century have seen radical improvements in survival outcomes. Nevertheless, in the third world, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death.[5]

Contents

1 Classification 2 Signs and symptoms 3 Cause

3.1 Bacteria 3.2 Viruses 3.3 Fungi 3.4 Parasites 3.5 Idiopathic 4.1 Viral 4.2 Bacterial 5.1 Imaging 5.2 Microbiology 5.3 Differential diagnosis 6.1 Vaccination 6.2 Environmental 6.3 Other 7.1 Bacterial 7.2 Viral 7.3 Aspiration 8.1 Clinical prediction rules 8.2 Pleural effusion, empyema, and abscess 8.3 Respiratory and circulatory failure

4 Pathophysiology

5 Diagnosis

6 Prevention

7 Management

8 Prognosis

9 Epidemiology

9.1 Children

10 History 11 Society and culture 12 References

Classification
Main article: Classification of pneumonia Pneumonitis refers to lung inflammation; pneumonia refers to pneumonitis, usually due to infection but sometimes non infectious, that has the additional feature of pulmonary consolidation.[6] Pneumonia can be classified in several ways. It is most commonly classified by where or how it was acquired (communityacquired, aspiration, healthcare-associated, hospital-acquired, and ventilator-associated pneumonia),[7] but may also be classified by the area of lung affected (lobar pneumonia, bronchial pneumonia and acute interstitial pneumonia),[7] or by the causative organism.[8] Pneumonia in children may additionally be classified based on signs and symptoms as non-severe, severe, or very severe.[9]

Signs and symptoms

Main symptoms of infectious pneumonia People with infectious pneumonia often have a productive cough, fever accompanied by shaking chills, shortness of breath, sharp or stabbing chest pain during deep breaths, confusion, and an increased respiratory rate.[10] In the elderly, confusion may be the most prominent symptom.[10] The typical symptoms in children under five are fever, Symptoms frequency in pneumonia[12] cough, and fast or difficult breathing.[11] Fever, however, is not very Symptom Frequency specific, as it occurs in many other common illnesses, and may be Cough 7991% absent in those with severe disease or malnutrition. In addition, a Fatigue 90% cough is frequently absent in children less than 2 months old.[11] Fever 7175% More severe symptoms may include: central cyanosis, decreased Shortness of breath 6775% thirst, convulsions, persistent vomiting, or a decreased level of [11] Sputum 6065% consciousness. Chest pain 3949% Some causes of pneumonia are associated with classic, but nonspecific, clinical characteristics. Pneumonia caused by Legionella may occur with abdominal pain, diarrhea, or confusion,[13] while pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum,[14] and pneumonia caused by Klebsiella may have bloody sputum often described as "currant jelly".[12]

Physical examination may sometimes reveal low blood pressure, a high heart rate, or a low oxygen saturation. Examination of the chest may be normal, but may show decreased chest expansion on the affected side. Harsh breath sounds from the larger airways that are transmitted through the inflamed lung are termed bronchial breathing, and are heard on auscultation with a stethoscope. Rales (or crackles) may be heard over the affected area during inspiration. Percussion may be dulled over the affected lung, and increased, rather than decreased, vocal resonance distinguishes pneumonia from a pleural effusion.[10] Struggling to breathe, confusion, and bluetinged skin are signs of a medical emergency.

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

Bacteria
Main article: Bacterial pneumonia

The bacterium Streptococcus pneumoniae, a common cause of pneumonia, imaged by an electron microscope Bacteria are the most common cause of community acquired pneumonia, with Streptococcus pneumoniae isolated in nearly 50% of cases.[19][7] Other commonly isolated bacteria include: Haemophilus influenzae in 20%, Chlamydophila pneumoniae in 13%, Mycoplasma pneumoniae in 3%,[7], Staphylococcus aureus, Moraxella catarrhalis, Legionella pneumophila and gram-negative bacilli.[16] Risk factors for infection depend on the organism involved.[16] Alcoholism is associated with Streptococcus pneumoniae, anaerobic organisms, and Mycobacterium tuberculosis, smoking is associated with Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Legionella pneumophila, exposure to bird with Chlamydia psittaci, farm animals with Coxiella burnetti, aspiration of stomach contents with anaerobes, and cystic fibrosis with Pseudomonas aeruginosa and Staphylococcus aureus.[16] Streptococcus pneumoniae is more common in the winter.[16]

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

Fungi
Main article: Fungal pneumonia

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

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

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

Pathophysiology

Pneumonia fills the lung's alveoli with fluid, hindering oxygenation. The alveolus on the left is normal, whereas the one on the right is full of fluid from pneumonia. Pneumonia frequently starts as a upper respiratory tract infection that moves into the lower respiratory tract.[23]

Viral
Viruses invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets are inhaled through the mouth or nose. Once in the lungs, the virus invades the cells lining the airways and alveoli. This invasion often leads to cell death, either from damage to the cell by the virus or from a protective process called apoptosis in which the infected cell destroys itself before it can be used as a conduit for virus reproduction. When the immune system responds to the viral infection, even more lung damage occurs. White

blood cells, mainly lymphocytes, activate certain chemical cytokines that allow fluid to leak into the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal transportation of oxygen into the bloodstream. As well as damaging the lungs, many viruses affect other organs and thus disrupt many body functions. Viruses can also make the body more susceptible to other bacterial infections; in this way bacterial pneumonia can arise as a co-morbid condition.[20]

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

Diagnosis
Crackles Crackles heard in the lungs of a person with pneumonia using a stethoscope.
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Pneumonia is typically diagnosed based on a combination of physical signs and a chest X-ray.[24] Confirming the underlying cause can be difficult, however, with no definitive test able to distinguish between bacterial and not-bacterial origin.[15][24] The World Health Organization has defined pneumonia in children clinically based on either a cough or difficulty breathing and a rapid respiratory rate, chest indrawing, or a decreased level of consciousness.[25] A rapid respiratory rate is defined as greater than 60 breaths per minute in children under 2 months old, 50 breaths per minute in children two months to one year old, or greater than 40 breaths per minute in children one to five years old.[25] In children, an increased respiratory rate and lower chest indrawing are more sensitive than hearing chest crackles with a stethoscope.[11] In adults, investigations are in general not needed in mild cases[26] as if all vital signs and auscultation are normal the risk of pneumonia is very low.[27]In those requiring admission to a hospital, pulse oximetry, chest radiography, and blood tests including a complete blood count, serum electrolytes, C-reactive protein, and possibly liver function tests are recommended.[26] The diagnosis of influenza-like illness can be made based on the presenting signs and symptoms however verification of an influenza infection requires testing.[28] Thus treatment is frequently based on the presence of influenza in the community or a rapid influenza test.[28]

Imaging

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

A chest radiograph is frequently used in diagnosis.[11] In people with mild disease, imaging is needed only in those with potential complications, those who have not improved with treatment, or those in which the cause in uncertain.[11][26] If a person is sufficiently sick to require hospitalization, a chest radiograph is recommended.[26] Findings do not always correlate with severity of disease and do not reliably distinguish between bacterial infection and viral infection.[11] X-ray signs of bacterial community acquired pneumonia classically show lung consolidation of one lung segmental lobe.[7] However, radiographic findings may be variable, especially in other types of pneumonia.[7] Aspiration pneumonia may present with bilateral opacities primarily in the bases of the lungs and on the right side.[7] Radiographs of viral pneumonia cases may appear normal, hyper-inflated, have bilateral patchy areas, or present similar to bacterial pneumonia with lobar consolidation.[7] A CT scan can give additional information in indeterminate cases.[7]

Microbiology
For people managed in the community figuring out the causative agent is not cost effective, and typically does not alter management.[11] For those not responsive to treatment, sputum culture should be considered, and culture for Mycobacterium tuberculosis should be carried out in those with a chronic productive cough.[26] Testing for other specific organisms may be recommended during outbreaks, for public health reasons.[26] In those who are hospitalized for severe disease both sputum and blood cultures are recommended.[26] Viral infections can be confirmed via detection of either the virus or its antigens with culture or polymerase chain reaction (PCR) among other techniques.[15] With routine microbiological testing a causative agent is determined in only 15% of cases.[10]

Differential diagnosis
Several diseases can present similar to pneumonia, including: chronic obstructive pulmonary disease (COPD), asthma, pulmonary edema, bronchiectasis, lung cancer, and pulmonary emboli.[10] Unlike pneumonia, asthma and COPD typically present with wheezing, pulmonary edema presents with an abnormal electrocardiogram, cancer and bronchiectasis present with a cough of longer duration, and pulmonary emboli presents with acute onset sharp chest pain and shortness of breath.[10]

Prevention
Prevention includes vaccination, environmental measures, and appropriately treating other diseases.[11]

Vaccination
Vaccination is effective for preventing certain bacterial and viral pneumonias in both children and adults. Influenza vaccines are modestly effective against influenza A and B.[15][29] The Center for Disease Control and Prevention (CDC) recommends that everyone 6 months and older get yearly vaccination.[30] When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.[31][32] Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae have good evidence to support their use.[23] Vaccinating children against Streptococcus pneumoniae has also led to a decreased incidence of these infections in adults, because many adults acquire infections from children. A vaccine against Streptococcus pneumoniae is also available for adults, and has been found to decrease the risk of PATHOPHYSIOLOGY

Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. Bacteria are the most common cause of pneumonia. Of these, Streptococcus pneumoniae is the most common. Other pathogens include anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia pneumoniae, C. psittaci, C. trachomatis, Moraxella (Branhamella) catarrhalis, Legionella pneumophila, Klebsiella pneumoniae, and other gram-negative bacilli. Major pulmonary pathogens in infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. Among other agents are higher bacteria including Nocardia and Actinomyces sp; mycobacteria, including Mycobacterium tuberculosis and atypical strains; fungi, including Histoplasma capsulatum, Coccidioides immitis, Blastomyces dermatitidis, Cryptococcus neoformans, Aspergillus fumigatus, and Pneumocystis carinii; and rickettsiae, primarily Coxiella burnetii (Q fever). The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents. Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae. Here are definitions of medical terms related to pneumonia. Bronchoscopy: A procedure in which a lighted, tube-like instrument is passed into the large air passageways of the lungs. Chlamydia: A type of bacteria that causes or is associated with various diseases of the eye, genitals, and urinary tract. It can sometimes cause pneumonia. Cilia: Delicate hairs that act as filters in the nose and upper airway, using a wave-like motion.

Cyanosis: The blue discoloration of skin, nailbeds, and mucous membranes that indicates low level of oxygen in the blood. Dyspnea: Difficulty breathing. Endotracheal Tube: An open-ended tube that is placed within the trachea in order to maintain an open airway and allow assisted breathing. Lung Biopsy: A test to obtain a specimen of lung tissue for examination. A needle, tube, or surgery is used to take the lung tissue sample. Meningitis: An inflammation of the membranes that surround the brain. Meningitis is usually used to refer to a bacterial disease that causes the inflammation. Mycoplasma pneumoniae: A specific kind of bacterium that can cause pneumonia. Mucous: Sticky phlegm or liquid in the respiratory tract. Pleura: The thin membranes that line the outside of each lung and the chest cavity. Pleural effusion: Any accumulation of fluid between the layers of the pleura. Pleural fluid: The fluid inside the membranes lining the lungs and chest cavity. Pneumococcal vaccine: A killed or weakened form of the pneumococcus bacteria that is given in order to increase a person's immunity to the pneumonia-causing bacteria. Pulmonary Edema: An abnormal accumulation of fluid in the lungs. Pus: A thick, opaque, and usually yellow-white fluid containing white blood cells, tissue debris, and microorganisms. Rales (crackles): Clicking, bubbling, or rattling sounds that occur when air moves through fluid-filled airways. Rhonchi: A coarse gurgling sound in the lungs that indicates the presence of thick fluid. Spirometry: A test performed by breathing into an instrument called a spirometer, which records the amount and rate of air that is inhaled during a specified time. Some of the test measurements are obtained by normal breathing, and other tests require forced inhalation and/or exhalation. Streptococcus pneumoniae (pneumococcus): The bacteria that most often cause pneumonia. About 40,000 pneumonia deaths in the United States each year can be traced to Streptococcus pneumonia. Thoracentesis: Using a long, thin needle inserted between the ribs to remove fluid from the pleura. Trachea: The main trunk of the hollow tube through which air passes on its way to and from the lungs. Vaccination: Giving a killed or weakened virus or bacteria in order to stimulate the immune system to protect the person from that organism at next exposure. Here are some frequently asked questions related to pneumonia. Q: Can there be complications from pneumonia? A: Complications from pneumonia may occur. Secondary infections, which are usually bacterial, may require an additional course of antibiotic treatment, sometimes with a different antibiotic. Rarely, a lung abscess may result from pneumonia. Prompt medical attention can prevent or eliminate most potential complications. Q: What is "walking pneumonia"? A: When physicians diagnose someone with walking pneumonia, they are usually talking about an infection with an organism called Mycoplasma pneumoniae. Walking pneumonia is most common between the ages of 5 and 15, and accounts for 70% of pneumonias in children aged 9 to 15. As a rule, mycoplasma pneumoniae infections are not highly contagious. The onset is often so gradual that it may not be noticed at first. A decrease in energy level may be the earliest sign, followed by cold symptoms. The person may complain of a headache, runny nose, and sore throat, and sometimes may have a fever. Unlike a cold, it gradually gets worse over about two weeks, with an increasingly moist cough and possible hoarseness as the disease settles into the chest. Mycoplasma infections are easy to treat, although the antibiotics most commonly prescribed for children are not useful. Mycoplasma is exceptionally sensitive, however, to erythromycin, clarithromycin (Biaxin),

azithromycin (Zithromax), and tetracyclines (only used over age 8). These medications are usually effective in five to seven days. Without treatment a person will likely remain sick for a month or more, and may develop complications. Q: Who pays for the needed vaccinations? A: Most private insurance plans will pay for both the pneumococcal and flu shots, although you should check with your carrier first. Medicare also pays for both shots in people who are older than 65. People with no medical insurance can take advantage of the many programs that will pay for the vaccines, especially for children. Information about these programs is usually available from your doctor, local hospitals, or county or state health departments. Q: My father lives in a nursing home. If he gets pneumonia will he have to be moved? A: If someone living in a nursing home develops pneumonia, they generally can remain in the nursing home to recover. The person usually does not need to be moved as long as his pulse, temperature, and breathing are not significantly abnormal and qualified health care professionals are available to monitor and treat him. If the pneumonia can be treated with oral, injectable, or intravenous antibiotics, hospitalization is not usually necessary. Q: Who should NOT get the vaccine? A: Individuals who have had a previous allergic reaction to any component of the pneumococcal vaccine (e.g., hives, difficulty breathing) should avoid vaccination. The vaccine should also be avoided during radiation therapy or chemotherapy. Pregnant women should not be vaccinated unless a doctor, nurse, or midwife advises it. Children less than 2 years old should not get the shot. People who have any immune system deficiencies or who have h