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Serious Complications of Pneumonia


Acute lower respiratory tract infections are a global public health problem. In the United States, they cause a greater burden of disease and death than any other infection. In the past 50 years, there has been little change in the mortality rates due to pneumonia and its complications.

The outcome of pneumonia depends on two main factors: the virulence of the organism and the lung inflammatory response.

In pneumococcal pneumonia, people’s innate immunity often fails to mount an effective defense. Pneumococcal pneumonia can kill as many as 5% of patients who get it.

In COVID-19 pneumonia, often the patients’ own inflammatory response can cause more direct lung injury, abnormal pulmonary function, and complications.

How does someone get pneumonia?

A history of various exposures (travel, animal, occupational, and environmental) can cause pneumonia, including these factors:

  • Exposure to contaminated air-conditioning or water systems – Legionella species.
  • Exposure to overcrowded institutions (jails, homeless shelters) – S pneumoniae, Mycobacteria, Mycoplasma, and Chlamydophila.
  • Exposure to several types of animals – Cats, cattle, sheep, goats (C burnetii, B anthracis (cattle hide), turkeys, chickens, ducks, or other birds (C psittaci); rabbits, rodents (F tularensis, Y pestis).

There are also aspiration risks with associated factors such as:

  • Alcoholism.
  • Altered mental status.
  • Anatomic abnormalities, congenital or acquired.
  • Drug use.
  • Dysphagia.
  • Gastroesophageal reflux disease (GERD).
  • Seizure disorder.

Comorbid conditions, such as asthma, COPD, smoking, and a compromised immune system are risk factors for H influenzae infection, plus:

  • Previous surgeries
  • Possibility of immunosuppression

Do different causes of pneumonia cause different symptoms?

Most patients develop nonspecific symptoms including fever, rigors, shaking chills, and malaise, in addition to a productive cough. Some pneumonias such as H influenza are more common in the winter or early spring.

The character of the sputum may suggest a particular pathogen causing the pneumonia, as follows:

  • S pneumoniae is classically associated with a cough productive of rust-colored sputum.
  • Pseudomonas, Haemophilus, and pneumococcal species may produce green sputum.
  • Klebsiella species pneumonia is classically associated with a cough productive of red currant-jelly sputum.
  • Anaerobic infections often produce foul-smelling or bad-tasting sputum.

How are patients’ risk of severity of infection or possible complications and prognosis determined?

There are two main prognostic models: CURB-65 and Pneumonia Severity Index (PSI).

These are scoring mechanisms that health care providers use to determine if the patient is a candidate for outpatient or inpatient treatment and who may require ICU care.

CURB-65

CURB-65 is a scoring system developed from a multivariate analysis of 1,068 patients that identified numerous factors that appeared to play a role in patient mortality. One point is given for the presence of each of the following:

  • C onfusion – Altered mental status.
  • U remia – Blood urea nitrogen (BUN) level greater than 20 mg/d
  • R espiratory rate –30 breaths or more per minute.
  • B lood pressure – Systolic pressure less than 90 mm Hg or diastolic pressure less than 60 mm Hg.
  • Age older than 65 years.

Current guidelines suggest that patients may be treated in an outpatient setting or may require hospitalization according to their CURB-65 score, as follows:

  • Score of 0-1 – Outpatient treatment.
  • Score of 2 – Admission to a medical ward.
  • Score of 3 or higher – Admission to intensive care unit (ICU).

The percentage of mortality at 30 days associated with the various CURB-65 scores increases with higher scores.

  • Score of 0 = 0.7% mortality.
  • Score of 1 = 2.1% mortality.
  • Score of 2 = 9.2% mortality.
  • Score of 3 = 14.5% mortality.
  • Score of 4 = 40% mortality.
  • Score of 5 = 57% mortality.

Pneumonia Severity Index assesses demographic factors, coexisting illnesses, findings on physical examination such as altered consciousness or increased respiratory rate, and laboratory findings such as low arterial oxygen or high blood glucose levels.

The combined total points make up the risk score, which stratifies patients into five PSI mortality risk classes, as follows:

  • 0-50 points = Class I (0.1% mortality).
  • 51-70 points = Class II (0.6% mortality).
  • 71-90 points = Class III (0.9% mortality).
  • 91-130 points = Class IV (9.3% mortality).
  • More than 130 points = Class V (27% mortality).

What are potential consequences or complications of pneumonia?

Some of the potential complications of bacterial pneumonia include the following:

  • Pericarditis (inflammation around the lungs and in the chest cavity).
  • Effusions (fluid build-up in the area around the lungs).
  • Destruction and fibrosis/organization of lung parenchyma with scarring.
  • Atelectasis (collapse of the lungs).
  • Bronchiectasis (damage to the tubes that carry air in and out of the lungs).
  • Necrotizing pneumonia (death of some of the lung tissue).
  • Frank cavitation (death of lung tissue that leaves empty spaces).
  • Empyema (infection around the lungs and in the chest cavity).
  • Pulmonary abscess (collection of pus around or in the lungs).
  • Bacteremia (blood infection).
  • Sepsis (extreme response to infection).
  • Middle ear infections.
  • Sinus infections.
  • Respiratory failure.
  • Acute respiratory distress syndrome (a serious condition when fluid builds up in the alveoli or tiny air sacs in the lungs preventing normal functioning).
  • Ventilator dependence.
  • Superinfection (additional infections other than pneumonia or other pathogens causing pneumonia at the same time).
  • Meningitis (infection of the lining of the brain and spinal cord).
  • Death.

How are pneumonia complications prevented?

The best approach to treating pneumonia is to assess the initial severity of the disease. Scoring using the above methods such as CURB-65 and PSI are helpful.

The most important determination is whether the patient needs hospitalization and at what level of care.

Antibiotic treatment and supportive measures such as fluids and oxygen and breathing treatments can be lifesaving. In some cases, such as COVID-19 pneumonia, anti-inflammatory medicines such as steroids and antiviral medicines are paramount to avoid complications such as need for ventilator support.

Conclusion

The best prevention is vaccination and avoidance of exposure.

For example, there are specific guidelines for the prevention of community acquired pneumonia such as pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13). There are now guidelines for COVID-19 vaccines as well.

Key takeaways

In the past 50 years, there has been little change in mortality rates due to pneumonia and its complications.

Pneumococcal pneumonia can kill as many as 5% of patients who get it.

In COVID-19 pneumonia, often the patients’ own inflammatory response can cause more direct lung injury, abnormal pulmonary function, and complications.

You can get pneumonia through various exposures, and there are aspiration and comorbidity factors as well.

There are two main prognostic models: CURB-65 and Pneumonia Severity Index.

Antibiotic treatment and supportive measures such as fluids and oxygen and breathing treatments can be lifesaving.

References:

Johns Hopkins. Pneumonia.

WebMD. Complications of Pneumonia.

Mayo Clinic. Pneumonia Diagnosis and Treatment.

Lim, W.S., van der Eerden, M.M., Laing, R., Boersma, W.G., Karalus, N., Town, G.I., Lewis, S.A., Macfarlane, J.T. (2003). Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax.

Sligl, W.I., Majumdar, S.R., Marrie, T.J. (2009). Triaging severe pneumonia: what is the "score" on prediction rules? Critical Care Medicine.

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