For reasons that I’ll get to later in this post, I’ve been learning about pneumonia. Did you know it’s the leading cause of hospital admissions in the US, apart from people giving birth? For children under the age of 5, it’s a leading cause of death worldwide. Twenty facts about pneumonia from the American Thoracic Society can be found here.
Cancer and heart attacks get a lot of press. Although it’s not talked about as much, pneumonia is also a big deal. Despite our efforts in healthcare, the death rate from pneumonia in Canada has had minimal improvement in ten years, in part due to our aging population.
In this post, I’m going to share what I’ve learned about community-acquired pneumonia from my internet digging and personal experience.
What is Pneumonia?
Pneumonia is inflammation of the tiny air sacs in the lungs (called alveoli). It’s usually caused by an infection, like a virus or bacterium. This leads to fluid or pus build up in the lungs, which can cause all sorts of problems by preventing oxygen from getting into the blood stream. Read more about pneumonia from the Canadian Lung Association here.
Pneumonia can range from mild to life threatening. It’s especially dangerous for young children, elderly people, and those with weakened immune systems. In Canada, we vaccinate people who are at risk for invasive pneumonia. We have access to four pneumococcal vaccines that work pretty well against the most common cause of bacterial pneumonia, S. pneumoniae.
Which is probably what I have.
My Experience with Pneumonia
Having a kid in daycare for the first time had brought so many sicknesses into our house. I’ve written about it here and here.
Just before Easter weekend, we all got sick again with fevers and a cough. We isolated over the weekend, and were generally feeling better by Monday.
But on Wednesday night, I got another fever. I was shivering uncontrollably, had muscle aches, and my chest hurt with breathing.
Not a great sign.
I felt a bit better the next morning, which provided some (false) reassurance. By later that same day, my symptoms were consistent with full-blown pneumonia. My fever spiked to 39.1 degrees, my home oxygen saturation was reading at 94%, and my heart rate jumped between 115 and 120. And I was having difficulty breathing at rest.
I probably should have gone to the emergency department at this point. However, since I’m currently on my emergency medicine rotation, I really didn’t want to go there. Instead, I went to bed, hoped I wouldn’t get worse overnight, and saw my family physician the next morning.
Now, I’m on antibiotics and feeling much better. I’m still tired, but my chest pain is better and I was able to walk for a bit without needing to stop to catch my breath. Pneumonia’s no joke!
Assessing Adults for Pneumonia
If an adult comes in to the clinic with fever and a new cough, I’m thinking pneumonia.
There are five signs and symptoms that are especially helpful to assess:
1. Temperature greater than 37.8
2. Heart rate over 100
3. Crackles
4. Diminished breath sounds
5. Absence of asthma
These are the components of the Heckerling score. Having four or five of the above has a likelihood ratio of 8.2 for pneumonia. My score was four. Having zero or one of them has a likelihood ratio of 0.3.
Not included in the score is asymmetric chest expansion. If someone’s chest isn’t expanding as much on one side, that has a whopping likelihood ratio of 44! (At some point in the future, I’ll do a post about likelihood ratios and how they change post-test probability. It’s a super important topic, but one that I need to work on explaining.)
Once a patient is diagnosed with pneumonia, it’s important to check whether they can be treated as an outpatient or not. The CURB-65 is a common scoring system to assess this, or CRB-65 if you don’t have access to someone’s blood urea nitrogen levels.
First-line treatment for community-acquired bacterial pneumonia in otherwise healthy adults is one gram of amoxicillin three times a day for five days. I’m almost through my five days, and I am so grateful for antibiotics.
These are just a few of the things I learned when I was looking things up for my own purposes. There’s a ton of nuance to this topic, like how to tell whether a pneumonia is viral or bacterial, what common conditions can mimic pneumonia, and what additional testing might be needed.
My personal experience reinforced the lesson that if symptoms aren’t getting better over a week or so, it’s important to get checked out.
For everyone with kids in daycare, I really hope we’re out of respiratory virus season soon!
Stay well friends,
Dr. Kuhnow
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