Pathophysiology

Specific pathophysiologic changes related to pneumonia vary according to the offending

pathogen. Almost all pathogens trigger an inflammatory response in the lungs (Fig. 27.1).
Inflammation, characterized by an increase in blood flow and vascular permeability, activates
neutrophils to engulf and kill the offending pathogens. As a result, the inflammatory process
attracts more neutrophils, edema of the airways occurs, and fluid leaks from the capillaries and
tissues into alveoli. Normal O2 transport is affected, leading to manifestations of hypoxia (e.g.,
tachypnea, dyspnea, tachycardia).

Atelectasis, the absence of gas or air in 1 or more areas of the lung, may occur with pneumonia.
It rarely causes any adverse effects except shortness of breath (Fig. 27.2). On the other hand,
consolidation, a feature typical of bacterial pneumonia, occurs when the normally air-filled
alveoli become filled with water, fluid, and/or debris (Fig. 27.3). This can potentially obstruct
airflow, impair gas exchange, and cause the signs and symptoms associated with bacterial
infection. Over time and with appropriate antibiotic therapy, macrophages lyse and process the
debris. This allows lung tissue to recover and gas exchange to return to normal.

Clinical Manifestations

The most common presenting symptoms of pneumonia are cough, fever, chills, dyspnea,
tachypnea, and pleuritic chest pain. The cough may or may not be productive. Sputum may be
green, yellow, or even rust colored (bloody). Viral pneumonia may initially be seen as influenza,
with respiratory symptoms appearing and/or worsening 12 to 36 hours after onset.

FIG. 27.2 Atelectasis. Scanning electron micrograph of lung parenchyma. A, Alveoli (A) and
alveolar-capillary membrane (arrow). B, Effects of atelectasis. Alveoli (A) are partially or totally
collapsed.

A, From Dantzker DR, Bone RC, George RB, eds: Pulmonary and critical care medicine, vol 1, St
Louis, 1993, Mosby. B, From Albertine KH, Williams MC, Hyde DM: Anatomy of the lungs. In RJ
Mason, VC Broaddus, JF Murray, et al, eds: Murray and Nadel’s textbook of respiratory
medicine, ed 4, Philadelphia, 2005, Saunders.

FIG. 27.3 Chest x-ray examination of patient with acute bacterial pneumonia.

© iStock.com/stockdevil.

The older or debilitated patient may not have classic symptoms of pneumonia. Confusion or
stupor (possibly related to hypoxia) may be the only finding. Hypothermia, rather than fever,
also may be seen in the older adult. Nonspecific manifestations include diaphoresis, anorexia,
fatigue, myalgias, and headache.

On assessment, fine or coarse crackles may be auscultated over the affected region. If
consolidation is present, bronchial breath sounds, egophony (an increase in the sound of the
patient’s voice), and increased fremitus (vibration of the chest wall made by vocalization) may
be present. Patients with pleural effusion may have dullness to percussion over the affected
area.

Complications

A major problem today is pneumonia caused by multidrug-resistant (MDR) pathogens. Common

culprits include MRSA and gram-negative bacilli. Risk factors for MDR pneumonia include
advanced age, immunosuppression, history of antibiotic use, and prolonged mechanical
ventilation. Antibiotic susceptibility tests can identify MDR pathogens. The virulence of these
pathogens can severely limit the available and appropriate antimicrobial therapy. MDR
pathogens increase the morbidity and mortality associated with pneumonia. (See Chapter 14 for
more about MDR pathogens.)

Other complications from pneumonia develop more often in older adults and those with
underlying chronic diseases. These include:

• Atelectasis

• Pleurisy, an inflammation of the pleura.

• Pleural effusion, or fluid in the pleural space. In most cases, the effusion is sterile and is
reabsorbed in 1 to 2 weeks. Sometimes, effusions require aspiration by thoracentesis.

• Bacteremia, bacterial infection in the blood, is more likely to occur in infections with
Streptococcus pneumoniae and Haemophilus influenzae.

• Pneumothorax can occur when air collects in the pleural space, causing the lungs to collapse.

• Acute respiratory failure is one of the leading causes of death in patients with severe
pneumonia. Failure occurs when pneumonia damages the lungs’ ability to exchange O2 and CO2
across the alveolar-capillary membrane.

• Sepsis/septic shock can occur when bacteria within alveoli enter the bloodstream. Severe
sepsis can lead to shock and multisystem organ dysfunction syndrome (MODS) (see Chapter 66).

Lung abscess is not a common complication of pneumonia. However, it may occur with
pneumonia caused by S. aureus and gram-negative organisms. Empyema, the accumulation of
purulent exudate in the pleural cavity, occurs in less than 5% of cases. It requires antibiotic
therapy and drainage of the exudate by a chest tube or open surgical drainage.9 Pleurisy,
pleural effusion, atelectasis, lung abscess, and pneumothorax are discussed later in this chapter.
Diagnostic Studies

The common diagnostic procedures for pneumonia are outlined in Table 27.4. History, physical
examination, and chest x-ray often give enough information to make immediate decisions about
early treatment. Chest x-ray often shows patterns characteristic of the infecting pathogen and is
important in diagnosing pneumonia. X-ray may also show pleural effusions. A thoracentesis
and/or bronchoscopy with washings may be used to obtain fluid samples from patients not
responding to initial therapy.

Arterial blood gases (ABGs) may be obtained to assess for hypoxemia (partial pressure of O2 in
arterial blood [PaO2] less than 80 mm Hg), hypercapnia (partial pressure of carbon dioxide in
arterial blood [PaCO2] greater than 45 mm Hg), and acidosis (pH less than 7.35). Leukocytosis
occurs in most patients with bacterial pneumonia. The white blood cell (WBC) count is usually
greater than 15,000/μL (15 × 109/L) with the presence of bands (immature neutrophils).

Ideally, a sputum specimen for culture and Gram stain to identify the organism is obtained
before beginning antibiotic therapy. However, antibiotic administration should not be delayed if
a specimen cannot be obtained. Delays in antibiotic therapy can increase the risk for morbidity
and mortality. Blood cultures are done for patients who are seriously ill.

ABLE 27.4 Interprofessional CarePneumonia

Diagnostic Assessment

• History and physical examination

• Chest x-ray

• Sputum: Gram stain, culture and sensitivity test

• Pulse oximetry or arterial blood gases (if indicated)

• CBC, white blood cell differential, and routine blood chemistries (if indicated)

• Blood cultures (if indicated)

Management

• Increased fluid intake (at least 3 L/day), IV fluids

• Balance between activity and rest

• O2 therapy

• Physiotherapy

• VTE prophylaxis
• Critical care management, with mechanical ventilation as needed

Drug Therapy

• Appropriate antibiotic therapy (Table 27.6)

• Antipyretics

• Analgesics

• Nonsteroidal antiinflammatory drugs (if no contraindications)

Serum levels of C-reactive protein (CRP), kallistatin, and procalcitonin are currently being
explored as sources of information to help distinguish pneumonia from other types of heart and
respiratory failure.1