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 INTRODUCTION ON PNEUMONIA

Pneumonia is an inflammatory condition of the lung primarily

affecting the small sacs known as alveoli. Though the severity of
of the condition is variable, each year, pneumonia affects about
450 million people globally (7% of the population) and results in
about 4 million deaths.

Pneumonia has been a common disease throughout human

history. The word is from Greek πνεύμονας (pneumon) meaning
“lung”. Hippocrates (c.460-370 BC) referred to pneumonia as a
disease “named by the ancients”. He also reported the result of
surgical drainage of emphysemas.

Edwin Klebs was the first to observe bacteria in the airways of

persons having died of pneumonia in 1875. Initial work
identifying two common bacterial causes Streptococcus
pneumoniae and Klebssiella pneumoniae, was performed by Carl
Friedländer and Albert Fraenkel in 1882 and 1884, respectively. In
1887, Jaccond demonstrated pneumonia may be caused by
opportunistic bacteria always present in the lungs.

Viral pneumonia was first described by Hobart Reimann in 1938,

Reimann, Chairman of the Department of Medicine at Jefferson
Medical College, had established the practice of routinely the
typing pneumococcul organism in cases where pneumonia

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presented. Out of this work, the distinction between viral and
bacterial strain was noticed.

Edwin Klebs Dr. Albert Fraenkel Carl Friedländer

(6 Feb 1834-23 Oct 1913) (3 June 1864-22 Dec 1938) (19 Nov 1847-13 May 1887)
These great people were pioneer of proving that Bacterial infection were one of the
main cause of pneumonia.

Several development in the 1900s improved the outcome for

those with pneumonia. With advent of penicillin and other
antibiotics, modern surgical techniques, and intensive care in 20th
century, mortality for pneumonia, which approached 30%,
dropped precipitously in the developed world. Vaccination of
infants against Heamophilus influenzae type B began in 1988 and
led to dramatic decline in cases shortly thereafter. Vaccination

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against Streptococcus pneumoniae in adults began in 1977, and in
children in 2000, resulting in a similar decline.

The absolute number of pneumonia deaths in India has declined

substantially since 2000. However, pneumonia remains a major
cause of morbidity in children in the country. Between 2000 to
2015, the estimated number of pneumonia cases in children
younger than 5 years decreased from 83.8 million cases to 49.8
million cases, representing a 41% reduction in pneumonia cases.
The estimated national pneumonia cases fatality rate in 2015 was
0.38%. in 2015, the estimated number of severe pneumonia cases
was 8.4 million, with an incidence of 68 in 1000 children and a
case fatality ratio of 2.26%.

15% of cases of COVID-19 are severe. Some of these cases give

rise to pneumonia that is caused by the corona virus which can be
fatal in later stages of the disease. Patients who are 65 or older
are at a higher risk.

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 Graph showing mortality rate of flu and Pneumonia before and after the Covid-19
surge in USA.

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 ANATOMY OF THE LUNGS AND HOW
PNEUMONIA AFFECTS THE LUNGS

The lungs are the major organs of the respiratory system, and
are divided into sections, or lobes. The right lung has three lobes
and is slightly larger than the left lung, which has two lobes. The
lungs are separated by the mediastinum. This area contains the
heart, trachea, oesophagus, and many lymph nodes. The lungs
are covered by a protective membrane known as the pleura and
are separated from the abdominal cavity by the muscular
diaphragm.

With each inhalation , air is pulled through the windpipe (trachea)

and the branching passageways of the lungs (the bronchi), filling
thousands of tiny alveoli at the ends of the bronchi. These sacs,
which resemble bunches of grapes, are surrounded by small
capillaries .Oxygen passes through the thin membranes of the
alveoli and into the bloodstream. The red blood cells pick up the
oxygen and carry it to the body's organs and tissues. As the blood
cells release the oxygen they pick up carbon dioxide, a waste
product of metabolism. The carbon dioxide is then carried back to
the lungs and released into the alveoli. With each exhalation
,carbon dioxide is expelled from the bronchi out through the
trachea.

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 Structure of Lungs and other parts of the respiratory system

Pneumonia an infection of the lungs that may be caused by

bacteria, virus or fungi. The infection causes the lungs’ alveoli to
become inflamed and fill up with liquid or pus. That can make it
hard for oxygen you breath in to get into your bloodstream. Thus,
making breathing hard due to lack of oxygen.

Diagram showing the affect of Pneumonia in lungs. Diagram A. Showing a healthy

alveoli, Diagram B. Showing alveoli during pneumonia infection.

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 MICRO-ORGANISMS CAUSING
PNEUMONIA IN HUMANS

In the previous topic we learnt how does pneumonia affects the

lungs, now in this chapter we will learn more about the bacteria,
virus and fungi that cause pneumonia in human.

Basic digram of bacteria, virus and fungi.

Streptococcus pneumoniae, or pneumococcus, is a gram-positive,

spherical bacteria, alpha-hemolytic (under-aerobic conditions) or
beta-hemolytic(under anaerobic conditions), facultative
anaerobic member of the genus Streptococcus. They are usually
found in pairs (diplococci) and do not form spores and are non
motile. As a significant human pathogenic bacterium
S.pneumoniae was recognized as a major cause of pneumonia in
the late 19th century, and is th subject of many humoral immunity
studies.

Streptococcus pneumoniae resides asymptomatically in a healthy

carriers typically colonizing the respiratory tract, sinuses and

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nasal cavity. However, in susceptible individuals with weaker
immune systems, such as the elderly and young children, the
bacterium may become pathogenic and spread to other locations
to cause disease. Its spreads by direct person-to-person contact
via respiratory droplets and by auto inoculation in persons
carrying the bacteria in their upper respiratory tracts. It can be a
cause of neonatal infections.

Streptococcus pneumoniae is the main cause of community

acquired pneumonia and meningitis in children and the elderly,
and of sepsis in those infected with HIV. The organism also causes
many types of pneumococcal infections other than pneumonia.
These invasive pneumococcal diseases include bronchitis, rhinitis,
acute sinusitis, otitis media, conjunctivitis, meningitis, sepsis,
osteomyelitis, septic arthritis, endocarditis, peritonitis,
pericarditis, celluitis, and brain abscess.

Streptococcus pneumoniae can be differentiated from the viridian

streptococcus some of which are also alpha-hemolytic, using an
optochin test, as S.pneumoniae is optochin-sensitive.
S.pneumoniae can also be distinguished based on its sensitivity to
lysis by bile, the so-called “bile solubility test”. The encapsulated,
Gram-positive, coccoid bacteria have a distinctive morphology on
Gram stain, lancet-shaped diplococci. They have polysaccharide
capsule that acts as a virulence factor for the organism; more
than 90 different serotypes are known, and these types differ in
virulence, prevalence, and extent of drug resistance.

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 View of Streptococcus pneumoniae under Microscope and Electron microscope.

Klebsiella pneumoniae is a Gram-negative, non-motile,

encapsulated, lactose-fermenting, facultative anaerobic, rod-
shaped bacterium.
Although found in the normal flora of the mouth, skin, and
intestines, it can cause destructive changes to human and animal
lungs if aspirated, specifically to the alveoli resulting in bloody,
brownish or yellow colored jelly like sputum. In the clinical
setting, it is the most significant member of the genus Klebsiella
of the Enterobacteriaceae. K.oxytoca and K.rhinoscleromatis have
also been demonstrated in in human clinical specimens. In recent
years, Klebsiella species have become important pathogens in
nosocomial infections.

Other than pneumonia, Klebsiella can also cause infection in the

urinary tract and surgical wound sites and it causes Clinical
diseases which include thrombophlebitis, cholecystitis,
diarrhoea, upper respiratory tract infection, osteomyelitis, and
bacteremia, and sepsis.

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New antibiotic-resistant strains of K.pneumoniae are appearing.
Thus, it has around 50% mortality rate, even with microbial
therapy.

View of Klebsiella pneumoniae under Microscope and electron microscope.

Mycoplasma pneumoniae is a very small bacterium in the class of

Mollicutes. Its is a human pathogen that causes the disease
mycoplasma pneumonia, a form of atypical bacterial pneumonia
related to cold agglutinin disease. M.pneumoniae is characterized
by absence of a peptidoglycan cell wall and resulting resistance to
many anti-bacterial agents. The persistence of M.pneumoniae
infections even after treatment is associated with its ability to
mimic host cell surface composition. Approximately 40% of
community-acquired pneumonia is due to M.pneumoniae
infections, with children and elderly individuals being most
susceptible, however no personal risk factors for acquiring
M.pneumoniae induced pneumonia have been determined.

Electron microscope image of

Mycoplasma pneumoniae

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Chlamydia pnemoniae is a small gram-negative bacterium, which
is the species of Chlamydia, and is an obligate intracellular
bacterium that infect humans and is a major cause of pneumonia.
It was known as the Taiwan acute respiratory (TWAR) from the
names of two original isolates: Taiwan (TW-183) and an acute
respiratory isolate designated AR-39.

The first known case of infection with C.pneumoniae was a case

of conjunctivitis in Taiwan in 1950. There are no known cases of
C.pneumoniae in human history before 1950. This a atypical
bacterium commonly cause pharyngitis, bronchitis, coronary
artery disease and atypical pneumonia in addition several other
possible disease.

Chlamydia pneumoniae under a microscope

Legionella pneumophila is a thin, aerobic, pleomorphic,

flagellated, non-spore-forming, Gram-negetive bacterium of the
genus Legionella. L.Pneumophila is the primary human
pathogenic in this group and is the causative agent of
legionnaires’ disease, also known as legionellosis.

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In nature, L.pneumophila infects freashwater and soil amoebae
of the genera Acanthamoeba and Naegleria. The mechanism of is
similar in Amoeba and human cells.

Microscopic view of Legionella pneumophila.

Respiratory Syncytial Virus (RSV), also called human respiratory

syncytial virus (hRSV) and human orthopneumovirus is a very
common, contagious virus that causes infections of the
respiratory tract. It is a negative-sense, single stranded RNA virus,
and its name is derived from the large cells known as syncytia
that form when infected cells fuse together.

RSV is the single most common cause of respiratory

hospitalization in infants, and reinfection remains common in
later age. It is an important pathogen in all age groups. Infection
rates are typically higher during the cold winter months, causing
bronchiolitis in infants, common cold in adults, and more serious
respiratory illnesses such as pneumonia in the elderly and
immunocompromised.

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RSV is spread through contaminated air droplets and can cause
outbreaks both in the community and in hospital settings.
Following initial infection via the eyes or nose, the virus will infect
the epithelial cells of the upper and lower airway tracts, causing
inflammation, cell damage, and airways obstructions. A variety of
methods are available for viral detection and diagnosis of RSV
including antigen testing, molecular testing and viral culture.
While the main prevention measure include hand washing and
avoiding close contacts with infected individual, a profilactic
medication called palivizumab is available to prevent RSV
infection on high-risk infants. Currently there is no vaccine against
RSV although many are under development.

Treatment for severe illness is primarily supportive including

oxygen therapy and more advanced breathing support with CPAP
or nasal high flow Oxygen, as required. In case of severe
respiratory failure, intubation and mechanical ventilation may be
required. Ribavirin is the only antiviral medication currently
licensed for the treatment of RSV in children although its used
remains controversial.

Structure and
Diagram of RSV

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Pneumocystis jirovecii is a yeast like fungus of the genus
pneumocystis. The causative organism of pneumocystis
pneumonia, it is a important human pathogen, particularly
among immunocompromised hosts. Prior to its discovery as a
human-specific pathogen, P.jerovecii was known as P.carinii.

Pneumocystis pneumonia is a important diesease of

immunocompromised humans particularly patients with HIV but
also patient with an immune system that is severely suppressed
for other reasons for example following a bone marrow
transplant. In humans with a normal immune system, it is an
extremely common silent infection.

P.jerovicii under electron microscope.

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 SIGNS & SYMPTOMS OF PNEUMONIA

Pneumonia symptoms can vary from mild that the doctors can
barely notice them, to so severe that hospitalization is required.
How the patients body response to pneumonia depends on the
type of germs causing the infection, the patient’s age and his/her
overall health.

The signs and symptoms of pneumonia may include:

 Cough, which ,may produce greenish, yellow or even bloody

mucus.
 Fever, sweating and shaking chills.
 Shortness of breathing.
 Rapid and shallow breathing
 Sharp or stabbing chest pain that gets worse when you
breath deeply or cough.
 loss of appetite, low energy, and fatigue.

 Nausea and vomiting, especially in small children.

 Confusing, especially in older patients.

Bacterial pneumonia, which is the most common form, tends to

be more serious than other types of pneumonia, with symptoms
that require medical care. The symptoms of bacterial pneumonia
can develop gradually or suddenly. Fever may rise as high as a
dangerous 105 degree Fahrenheit, with profuse sweating and
rapidly increase breathing and pulse rate. Lips and nail-beds may
have a bluish colour due to lack of oxygen in the blood. A
patient’s mental state may be confused or delirious.
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The symptoms of viral pneumonia usually develop over a period
of several days. Early symptoms are similar to influenza
symptoms: fever, a dry cough, headaches, muscle pain, and
weakness. Within a day or two, the symptoms typically get worse,
with increasing cough, shortness of breath and muscle pain.
There may be high fever and there may be blueness of the lips.

Symptoms may vary in certain populations. Newborns and infants

may not show any sign of the infection. Or, they may vomit, have
a fever and cough, or appear restless, sick, or tired and without
energy. Older adults and people who have serious illness or weak
immune systems may have fewer and milder symptoms. They
may have pneumonia sometimes have sudden changes in mental
awareness. For individuals that already have a chronic lung
disease, those symptoms may worsen.

AETIOLOGY OF PNEUMONIA

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There are many different causes of Pneumonia, mainly they are
caused by bacteria, virus or fungi. The main causative agent is
Streptococcus and other viruses. But pneumonia is caused when
the immunity of a person is weak or hampered due to other
diseases like AIDS or Lung cancer. A person smoking can be
affected by pneumonia also. Though Smoking may not directly
influence pneumonia but many people are affected by
pneumonia if they have lung cancer.

Pneumonia is a contagious disease, meaning that they can easily

spread among people. Community acquired pneumonia is when
someone develop pneumonia in the community and the Bacteria
or virus spread through him/her to others. Example An
asymptomatic Pneumonic person sneezing in the office can cause
symptomatic pneumonia to a person with weaker immunity.
Healthcare associated pneumonia is when someone develops
pneumonia during or following a stay in a health care facility.
Health care facility include hospitals, long term care facility or
dialysis centers.Ventilator associated pneumonia is when
someone gets pneumonia after being on a ventilator, a machine
that supports breathing. The bacteria and virus that most
commonly cause pneumonia in the community are different from
those in healthcare settings.

TYPES OF PNEUMONIA
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The classification of pneumonia is based on many factors like
the organism causing the disease, area of the lung affected by the
disease, and the primary disease.

MICRO-ORGANISMS CAUSING PNEUMONIA TYPES

Bacterial Pneumonia : Bacterial pneumonia is an infection of the

lungs caused by certain bacteria. The most common one is
Streptococcus(pneumococcus), but the other bacteria can cause
it too. If the person is young and healthy, these bacteria can live
in their throat without causing any trouble. But if the person’s
immune system becomes weak for some reason,the bacteria can
go down to the person’s lungs. When this happens, the air sacs in
the lugs get infected and inflamed. They are filled with fluid, and
causes pneumonia.

Viral Pneumonia: Viral pneumonia is an infection of your lungs

caused by a virus. The most common cause is the flu, but a
person can also get viral pneumonia from the common cold and
other viruses. The virus usually stick to the upper part of the
person’s respiratory system. But the trouble starts when they get
down into your lungs. The the air sacs in the person’s lungs get
infected and inflamed and they fill up with fluid.

Mycoplasma pneumonia: Mycoplasma pneumonia is a contagious

respiratory infection that spread easily through contact with
respiratory fluids. It can cause epidemics.

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Mycoplasma pneumonia is known as an atypical pneumonia and
is sometimes called “walking pneumonia”. It spreads quickly in
crowded areas, such as schools, college campuses, and nursing
homes. When an infected person coughs or sneezes, moisture
containing the mycoplasma pneumonia bacteria is released into
the air. Uninfected people in their environment can easily breathe
the bacteria in.

Up to one-fifth of all lung infections that people develop in their

community are caused by Mycoplasma pneumoniae bacteria. The
bacteria can cause tracheobronchitis (chest colds), sore throats,
and ear infections as well as pneumonia.

TYPES OF PNEUMONIA DEPENDING ON THE AREA OF THE

LUNGS AFFECTED.

Initial descriptions of pneumonia focused on the anatomic or

pathogenic appearance of the lung, either by direct inspection at
autopsy or by its appearance under a microscope. Different types
are as follows:

1. 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).

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

3. Bronchial pneumonia affects the lungs in patches around the

tubes (bronchi or bronchioles)

4. 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

TYPES OF PNEUMONIA BASED ON THE CAUSE

Pneumonia has historically been characterized as either typical

typical or atypical depending on the presenting symptoms and
thus thus the presumed underlying organism. Attempting to make
this distinction based on symptoms, however, has not been found
to be accurate.

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Bronchiolitis obliterans organizing pneumonia

Bronchiolitis obliterans organizing pneumonia (BOOP) is caused

by inflammation of the small airways of the lungs. It is also known
as cryptogenic organizing pneumonitis (COP).
Eosinophilic pneumonia is invasion of the lung by eosinophils, a
particular type pf 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 skin contact. When the toxic substance
is an oil, pneumonia may be called lipid 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 lungs inflammation is
not an infection but can contribute to one, since the material
aspiration may contain anaerobic bacteria or other usual 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 defences.

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Dust pneumonia

Dust pneumonia describes disorders caused by excessive

exposure to dust storms. With dust pneumonia, dust settles all
the way into the alveoli of the lungs, stoppinng the cilia from
moving and preventing the lungs from ever clearing themselves.

Necrotizing pneumonia

Necrotizing pneumonia (NP), also known as cavity pneumonia or

cavitatory necrosis, is a rare but severe complication of lung
parenchymal infection. In necrotizing pneumonia, there is a
substantial liquefaction following death of the lung tissue ,which
may lead to gangrene formayiom in the lung. In most cases
patients with NP have fever, cough, and bad breath, and those
with more indolent infections have weight loss. Often patients
clinically present with acute respiratory failure. The most
common pathogens responsible for NP are Streptococcus
pneumonia, Staphylococcus aureus, Klebsiella pneumoniae.

Opportunistic pneumonia

People with weakened immune defence, such as HIV/AIDS

patients, are highly susceptible to opportunistic infections
affecting the lungs. Most common pathogens are Pnemocystis
jeroveci, Mycobacterium avium-intacellulare complex,
Streptococcus pneumoniae, Haemophilus species. Less frequent
pathogens are Cryptococcus neoformans, Histoplasma
capsulatum, Coccidioides immitis, cytomagalovirus (CMV) and
Toxoplasma gondii.

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Chemotherapy- induced immunodeficiency may lead to severe
lung infections. Pathogens commonly associated with lung
infections are bacteria, viruses, and fungi.

Double pneumonia (bilateral pneumonia)

This is a historical term for acute lung injury (ALI) or acute

respiratory distress syndrome (ARDS). However, the term was
and, especially by lay people, still is used 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

Severe acute respiratory syndrome (SARS) is highly contagious

and deadly type of pneumonia which first occured in November
2002 after intial outbreak in china caused by SARS-CoV/ SARS-
CoV-1, which almost disappeared by the month of May 2004. the
second outbreak of SARS-CoV-2 started in December 2019 from
Wuhan, China and was declared pandemic by WHO on 11 March
2020. SARS is caused by the SARS coronavirus, a previously
unknown pathogen.

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 RISK FACTORS OF PNEUMONIA

In epidemiology, a risk factor or determinant is a variable

associated with an increased risk of disease or infection.
Determinant is often used as a synonym. Here in this chapter we
will mainly look upon the risk factors of pneumonia.

➢ Continuous Smoking
➢ Age < 50 years
➢ Cold weather
➢ Air pollution
➢ URI (upper respiratory infection)
➢ AIDS
➢ Malnutrition
➢ Alcoholism
➢ Head injury
➢ Seizure disorder
➢ Drug overdose
➢ General anaesthesia
➢ Immune suppressive therapy
➢ Diabetes Mellitus
➢ Heart disease
➢ Lung disease
➢ Renal disease
➢ Cancer
➢ Aspiration of food, fluid, vomitus
➢ Inhaltion of toxic chemical gases, etc

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 Note: From alcoholism to immune suppressive therapy, the
risk factors can collectively called Altered consciousness
level and from Diabetes Mellitus to Cancer can collectively
called Chronic disease.

Risk factors of Pneumonia

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 PATHOPHYSIOLOGY OF PNEUMONIA

Pathophysiology is a convergence of pathology with physiology-

is the study of the disordered physiological process that cause,
result from, or are otherwise associated with a disease or injury.
In this chapter we will see the pathophysiology of pneumonia.

Step 1: Due to any cause, e.g, bacteria, virus or other

Step 2: Inflammation in Alveoli

Step 3: Mast cell activate and release:

a: Histamine
b: Prostaglandin
c: Cytokines
d: Leukotrienes

Step 4: Due to cytokines release, fluid shifts to extracellular space

(capillary permeability)

Step 5: Alveoli filled with fluid

Step 6: Consolidation

Step 7: Decrease oxygen saturation in body

Step 8: Hypoxemia / Hypoxia

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 DIAGNOSTIC EVALUATION

Pneumonia affects millions of people every year. So it is

important to know how to carefully and effectively evaluate the
disease, so that it can be properly treated.

To diagnose pneumonia physical examination is done. Fever,

cough, and shortness of breath are common symptoms of
pneumonia. The nurse or doctor checks the patients vital sign and
take detailed medical history and the also check the oxygen level
as it is very important. If the oxygen level is low the patient has
to given oxygen with the help of artificial oxygen. The doctor uses
the stethoscope to hear the wheezing ssound from the lungs

Various lab test are being done to confirm pneumonia as physical

examination only raises the suspicion of pneumonia. These lab
test are explained below with detail.

Complete blood count

A complete blood count is a simple and inexpensive test. A white

blood count is one of the blood counts measured. If it is elevated
infection or inflammation is present. But it does not specifically
let us know if the patient has pneumonia.

Procalcitonin

Procalcitonin is a precursor of calcitonin, a protein that is released

by cells in response to toxins. It is measured via a blood test.
Interestingly, the levels increases in response to bacterial
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infection but decreases in viral ones. Results are usually positive
within hours of bacterial infection and peak within 12 to 48 hours.
While it does not let us know what type of bacteria is present, it
indicates that what antibiotic treatment may be necessary.

Sputum Culture and Gram Stain

The best way to diagnosing pneumonic bacteria is through

culture. Unfortunately, collecting a good quality sputum sample
can be difficult, especially if the patient has a dry cough. It often
gets contaminated with normal bacteria that live in the
respiratory tract. Once the sputum is collected, a Gram stain is
applied to part of the specimen and examined under microscope.
A good quality sputum sample will show several white blood cells
but few epithelial cells. Bacteria will appear red or violet and
based on their appearance, can be categorized as one of two
classes of bacteria. Narrowing the diagnosis makes it easier to
choose an appropriate antibiotic.

To find out what specific bacteria is causing your illness, your

sample will be cultured in petri dishes. Onve the bacteria or fungi
grow, it is tested against diffrent antibiotics to see what treatment
will be most effective.

The problem is that it may take days ti get a definitive culture

result. Akso, certain bacteria like S.pneumoniae are difficult to
grow and can give false-negative results. Because of the
challenges in a good-quality sample, this test is more commonly
used for people in hospital rather than those living in the
community.

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 Gram stained S.pneumoniae and its culture.

Urine Antigen Test

Bacterial pneumonia caused by S.pneumoniae and Legionella

species has a high incidence of complications. Antigens from
these bacteria are excreted in the urine. A simple urine test is
available to look for these antigens.

The results are rapidly available and studies have shown them to
be more accurate than Gram stain or culture. Another advantage
of the test is that treatment with antibiotics will not alter the
results.

The problems is that urine antigen tests are less accurate in

milder cases of pneumonia. It also only test for one serotype of
Legionella although there are many species. Also, unlike with
culture, there is no way to use the results to determine what
antibiotics would be most effective for treatment.

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Serology

Some bacteria are difficult to grow in culture and do not have a

urine antigen test available for screening. Chlamydia,
Mycoplasma, and some Legionella species are atypical bacteria
that fall into this category.

these are serologic blood tests that may be able to determine

when and if the patient have been infected. Serology measures
antibodies formed against a specific pathogen. IgM antibodies
usually show that you have been infected in the past. It can
sometimes be difficult to know when IgM antibodies transitioned
to IgG antibodies.

PCR and Enzyme Immunoassays

It can be difficult to culture a virus. Instead, viral infections are

more commonly diagnosed using polymerase chain reaction
(PCR) and enzyme immunoassays. To perform any of these tests,
a sample must be collected. Depending on what virus is being
considered , this sample can be blood, sputum, nasal secretions,
or saliva. PCR is a test that screens for the presence of speific viral
or bacterial DNA in a sample. It is an alternative to serology to
screen for often available in one to six hours, PCR cannot be
performed on-site. It must be processed by a laboratory.

Enzyme immunoassays, however, can be performed as a point of

care test with results available in 15 minutes to an hour. These
immunoassays use antibodies to detects the presence of specific
viral antigens and screen for multiple viruses at one time.

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Pneumonia is common complication of COVID_19 testing, the
most accurate specimen is collected from the m=nose. This is the
part of the upper respiratory tract where concentrations of the
virus may be greatest. A flexible six-inch cotton swab is inserted
into the nose and along the back of the patient’s throat where it
is left in place for 15 seconds.

The same swab us then inserted into the other nostril to

maximize how much mucous is collected for the test. Studies are
then performed to assess of genetic material from the corona
virus is present.

IMAGING

Imaging studies are often performed before laboratopry tests. If

you are otherwise healthy, a healthcare provider may treat you
for pneumonia based on physical exam and imaging studies
alone.

Chest X-ray

If pneumonia is suspected based on symptoms and physical

exam, the standard of care is to get a chest X-ray. A chest X-ray
may show an infiltrate, which is a collection of pus, blood, or
protein in the lung tissue. It can also reveal other signs of lung
disease like cavitations and pulmonary nodules.

CT Scan

It is possible that a chest X-ray can miss a diagnosis. If your

healthcare provider still has a high suspicion for pneumonia after
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a negative result, she may choose to confirm the diagnosis by CT
scan. Generally speaking, a CT scan is more accurate than a chest
X-ray although it cost more and exposes you to higher doses of
radiation.

The test is performed by placing the patient flat in a donut-

shaped machine that takes pictures. The study is painless and
completed in minutes, but it is important to lie still during the test
to get the best images.

X-ray and CT scan of patient with pneumonia

Bronchoscopy

In severe cases that do not respond to therapy, the healthcare

provider may pursue futher imaging to look for other causes. This
evaluation may include bronchoscopy, where a thin camera is
guided through your nose or mouth down into your lungs.

Bronchoscopy visualizes big airways (trachea or windpipe and

large bronchi) – not lungs. The practitioner may decide to take
some fluid from the patient’s airway for culture if the patient’s
phlegm culture is negative and the patient is immunosurppressed
or the patient has a chronic illness requiring a precise diagnosis of

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the cause of the patient’s pneumonia. Bronchoscopy is almost
never done in an otherwise healthy adult with community
acquired pneumonia.

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 COMPLICATIONS CAUSED DUE TO
PNEUMONIA

When a patient gets pneumonia- whether it was caused by

bacteria, a virus or a fungus- there is a chance it would lead to
other medical complications. Let us study about this complication
in detail in this chapter, so that the treatment is correct and that
the primary disease does not give rise to other secondary
complication.

Bacteremia and Septic Shock

If bacteria causing pneumonia, reaches into the patient’s blood,

and causes abnormality in blood due to the change in sterile
environment of blood is known as bacteremia.

Bacteremia can have several important health consequences. The

immune response to the bacteria can cause sepsis and septic
shock, which has a high mortality rate. Bacteria can also spread
via the blood to other parts of the body causing infections away
from the original site of infection, such as endocarditis or
osteomyelitis. Due to the infection the blood pressure may drop
dangerously and cause multi-organ failure leading eventually to
death. Treatment for bacteremia is with antibiotics, and
prevention with antibiotic prophylaxis can be given in high risk
situations.

Lung abscesses

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Sometimes pneumonia can cause pockets of pus to build up in
the patient’s lungs. Lung abscess is a type of liquefactive necrosis
of the lung tissue and formation of cavities (more than 2 cm)
containing necrotic debris or fluid caused by microbial infection.

This pus-filled cavity is often caused by aspiration, which may

occurs during anesthesia, sedation, or unconsciousness from
injury. Alcoholism is the most common condition predisposing to
lung abscesses.

Broad spectrum antibiotic to cover mixed flora is the mainstay of

treatment. Pulmonary physiotherapy and postural drainage are
also important. Surgical procedures are required in selective
patients for drainage or pulmonary resection. The treatment is
divided according to the type of abscess, acute or chronic.

Pleural effusions, Empyema, and Pleurisy

There are two layers of tissue surrounding your lungs called the
pleura. One wraps around the outside of the lungs and other lines
the parts of the chest where the lungs sit. They help the lings to
move smoothly when you breathe.

If pneumonia is not treated, the pleuta can get swollen, creating a

sharp pain when a person breathe in. If the pleura is not been
treated, the area between the pleura may fill with fluid, which is
called pleural infusion. If the fluid gets infected, it leads to a
problem called empyema.

For pleural effusion and empyema, the doctor may suggest a

procedure that removes fluid from the patient’s body with a
40
needle. Antibiotics are also an option to treat empyema, and for
pleurisy, medication that stop swelling can be used.

Respiratory Failure

When the patient have pneumonia, it is possible that lungs is

filled with fluid. If that happens, the lungs will not be able to
transfer enough oxygen to the blood or get rid of the carbon
dioxide in the blood. It is a serious condition because organ need
oxygen to survive.

If the patient’s immune system is weak, have a history of

alcoholism or is elderly the risk of respiratory failure. The best
treatment is to provide oxygen through external means and to
give antibiotics for pneumonia so that the medicine can treat the
infection of pneumonia.

Renal and Cardiac failure

Due to bacteremia the kidney and heart can get infected and also
if the oxygenated blood does not reach these organs in adequate
amount then the organ will fail to perform properly, thus causing
more complication. So in this case the heart and kidney is treated
for infection. In serious case dialysis is used for renal failure and
artificial breathing is provided.

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 MEDICAL MANAGEMENT

Pneumonia is treated differently depending on the

microorganism that cause it. But vaccine and antibiotic therapy
are mostly used and symptomatic treatment is also given to the
patients.

Vaccination for pneumonia

Vaccination is found for bacterial pneumonia and there is no

vaccine for viral or fungal pneumonia.

1. Pneumococcal polysaccharide vaccine (PPSV) also known as

Pneumovax 23 (PPV-23)- is the first pneumococcal vaccine
derived from a capsular polysaccharide, and an important
landmark in medical history. The polysaccharide antigens were
used to induce type-specific antibodies that enhanced
opsonization, phagocytosis, and killing of Streptococcus
pneumoniae (pneumococcal) bacteria by phagocytic immune
cells. The pneumococcal polysaccharide vaccine is widely used in
high-risk adults. As a result, there have been important
reductions in incidence, morbidity, and mortality from invasive
pneumococcal disease. It targets 23 serotypes of Streptococcus
penumoniae.

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2. Pneumococcal conjugate vaccine (PCV) is a pneumococcal
vaccine and conjugare vaccine used to protect infants, young
children and adults against disease caused by the bacterium
Streptococcus pneumoniae (pneumococcus). It contains purified
capsular polysaccharide of pneumococcal serotypes conjugated
to a carrier protein to improve antibody response compare to the
pneumococcal polysaccharide vaccine. The World Health
Organization (WHO) recommends the use of the conjugate
vaccine in routine immunizations given to children. There are five
types of PCV available, with the brand names Prevnar 20, Prevnar
13, Synflorix, Pneumosil, which was prequalified by the WHO in
2020, and Vaxeuvance.

The most common side effect in children are decrease appetite,

fever (only very common in children aged six week to five years),
irritability , reactions at site of injection (reddening or hardening
of the skin, swelling, pain or tenderness), somnolence
(Sleepiness), and poor quality sleep. In adults and the elderly, the
most common side effects are decreased appetite, headaches,
diarrhea, fever (only very common in adults aged 18 to 29 years),
vomiting (only very common in adults aged 18 to 49 years), rash,
reactions at the site of injection, limitation of arm movement,
arthralgia and myalgia( joint and muscle pain), chills and fatigue.
For the prophylactiv use of paracetamol to reduce common,
minor adverse reaction is recommended for PCV.

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Antibiotic therapy for treatment of pneumonia

Antibiotics works in two different ways toward the bacteria or

Fungus that cause pneumonia the first way is to inhibit the
growth of bacteria by binding antibiotic’s RNA to the bacteria’s
RNA to stop production important protein needed for
reproduction. And the second is to bind with cell wall of the
organism and causing damage and destruction cell wall and
eventually to cell lysis. Example for such antibiotics are
Erthromycin, Cephalosprin, Amikacin, Ampicillin, Ceftriaxone, etc.

Bronchodilators

Bronchodilator is used to increase airflow , alleviate symptoms

and decrease exacerbation rates. Eg. Ventolin, Proventil, etc.

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Analgesics and Other drug to treat symptoms of pneumonia

For chest pain and fever analgesics can be used. Eg, Nimuslide,
paracetamol.

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 NURSING MANAGEMENT OF PATIENT
SUFFERING FROM PNEUMONIA

Nursing management consist of the performance of the

leadership functions of governance and decision making within
organizations employing nurses. It includes processes common to
all management like planning, organizing, staffing, directing and
controlling. In the below points we will look into the nursing
management of patient suffering with pneumonia.

 We should encourage the patient to take plenty of fluid,

provide warm liquids.
 Provide drugs as prescribed, e.g., bronchodilators,
anticholonergics, leukotrine, antagonists, methylxanthines,
anti-inflammatory.
 Provide humidification (room humidifier).
 Monitor ABGs, pulse oximetry to detect hypoxia.
 Provide fowler’s or semi-fowler position to expand lung
properly and relieve dyspnea.
 Assess colour of mucus membrane or skin for detection of
cyanosis.
 Administer supplemental oxygen as directed.
 Maintain adequatehydration and nutrition to improve
resistance to disease and reduce risk infection.
 Administer antimicrobial agents as prescribed.

Nursing diagnosis

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  Ineffective airways clearance related to alveolar
inflammation, edema formation, sputum production,
pleuritic pain.
 Impaired gas exchange related to hypoventilation (altered
oxygen supply), inflammation of alveoli.
 Risk of infection related to immunosuppresion, chronic
disease, inadequate ciliary action to defenses.
 Activity intolerance realted to hypoxia, or imbalance of
oxygen , supply and demand, fatigue.
 Acute pleuratic pain related to inflammatory process of lung
parenchyma, chronic and persistent coughing.
 Imbalanced nutrition less than body requirements related to
anorexia, sputum production, fever, bronchodilator
treatment, odour and taste of sputum.
 Risk of deficient fluid volume related to increase fluid loss
due to fever diaphoresis, mouth breathing.
 Deficient knowledge realted to disease condition (here
pneumonia).
 Ineffective breathing pattern related to decrease lung
expansion (fluid accumulation in lungs) and inflammatory
process.
 Anxiety related to disease.

Nursing interventions

For ineffective Airway clearance

a) Assess respiratory rate.
b) Auscultate breathing sounds (wheezing sound).
c) We should encourage the patient to take plenty of fluid,
provide warm liquids.
d) Keep environmental pollution to a minimum.
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 e) Provide drugs as prescribed, e.g. , bronchodilator,
anticholinergics, leukotrine, antagonists, methylxanthines,
anti-inflammatory.
f) Nebulize the patient with anticholinergic, e.g.,
Ipratropium bromide.
g) Suctioning may be done if excess mucus secretionfilled in
airway.
h) Provide mucolytics to facilitate thick sputum to expel out.
i) Monitor ABGs, pulse oximetry to detect hypoxia.
j) Elevate head of bed, change position regularly. Provide
fowler’s or semi-fowler position to expand lung properly and
relieve dyspnea.
k) Teach and encourage effective cough and deep
breathing techniques.

Impaired gas exchange

a) Assess colour of mucus membrane or skin for detect
cyanosis.
b) Assess respiratory rate and depth.
c) Monitor ABGs and pulse oximetry.
d) Provide Fowler’s position to patient.
e) Encourage expectoration of sputum, suction if necessary,
provide mucolytics.
f) Administer supplemental O2 as indicated.
g) Encourage for bed rest to reduce oxygen consumption.
h) Administration of medications as prescribed, e.g., mucolytic,
expectorants, brochodilators to reduce brochospasm to clear
airway to facilitate normal breathing.
i) We should monitor vital signs and cardiac rhythm.

Ineffective Breathing Pattern

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 a) Auscultate breathing sound and patterns of breathing.
b) Evaluate respiratory function, rapid/shallow respiration,
dyspnea, air hunger.
c) Assist patient with painful area during during coughing,
deep breathing to more effective and less traumatic
coughing.
d) Encourage patient to sit up as much as possible.
e) Provide medications as prescribe, e.g., bronchodilator,
anticholinergics, mucolytics.

Activity intolerance
a) Assess dyspnea, weakness, fatigue and vital signs.
b) Assist patient to take comfortable position for rest (head of
bed should be elevated)
c) We should assist patient with self care activities as needed
to make balance O2 supply and demand.
d) Encourage to consume nutritional diet to provide enough
energy.

Pleuritic pain/ acute painless

a) Assess location, characteristics, intensity of pain, e.g.,
continuous, aching , stabbing , burning.
b) Monitor vital signs.
c) We should encourage use of relaxation/breathing exercise.
d) Administer analgesics and antitussives as prescribed to
suppress cough and excess mucus.
e) Provide comfort measures ,e.g., frequently changes of
position, back rubs, support with pillow.
f) Nurse should assist and instruct patient in chest splinting
technique while coughing episodes to reduce chest
discomfort.
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Imbalanced nutrition less than body required
a) We should identify factors that contributes nausea, vomiting,
e.g., copious sputum, aerosol treatment, dyspnea, pain.
b) Auscultate bowel sounds to detect decrease gastric motility
and constipation due to decrease activity, limited fluid
intake.
c) Provide covered container for sputum and replace them
frequently to eliminates smell from patient’s environment
and reduce nausea.
d) We should encourage or teach about frequent oral care.
e) Nurse should to make a schedule for respiratory treatments
as least 1 hour before meal.
f) Encourage to avoid very hot and very cold foods to reduce
coughing.
g) Encourage rest period of 1 hours before and after meals to
reduce fatigue.

Risk of infections
a) Nurse should monitor vital signs to detect complications of
infection.
b) We should note risk factors for occurrence of infection.
c) Maintain sterile Suctioning techniques.
d) Maintain or limit visitors.
e) Avoid contact with persons with respiratory infections.
f) We should assist patient to change position frequently and
provide good pulmonary toilet.
g) Administer antimicrobials agents as prescribed.
Deficient knowledge

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 a) We should explain the disease, process factors affecting it,
preventing measures to the patient to understanding
disease.
b) Teach the patient for breathing exercise, coughing
effectively.
c) Teach self care management plan to patient.
d) Nurse should discuss importance of regular medical follow
up care to monitor disease process.
e) Teach the technique to use inhalers and time when they are
use to decrease symptoms, e.g., how to hold it, pausing 2-5
minute between puffs, cleaning the inhaler.

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 CONCLUSION

A bout 4 million die due to pneumonia every year around the

world. Many of those patient are children and elderly. To save
ourself from pneumonia we should wear mask and boil the water
we drink.

Due to lung cancer and CoVID-19 the death toll due to

pneumonia has risen since 2020. But vaccine for CoVID-19 has
come out and slowly the the situation is coming into control due
the lock down all around the world for about 1 year. Many will
continue to die due to pneumonia if we don’t take proper
precaution. So we should wear mask and avoid populated area.

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