PNEUMONIA - Full extract 

Stuart Taylor is a war veteran who shifted to our area several years ago. He is about 75 years of age and is a keen member of the local lawn-bowling club. He has been divorced for many years and lives in a flat near the surgery. 

He used to smoke heavily but finally gave them up about four years ago, after a severe attack of asthma. Since that time his asthma has been well controlled with preventive medications but he still needs occasional Ventolin. 

He gave me a call one night, just as I was about to leave the surgery. " My asthma's been playing up," he said. " The pump fixes it for a while but I feel bloody awful." 

When I called to see him, it was fairly obvious that he was very sick. He had the shivers and shakes and had a fever of 39 C. He was also more breathless than normal despite just coming off the Ventolin pump. His blood pressure was okay but he was dry in the mouth and looked a little dehydrated. He was slightly confused, and asked me a few times whether his wife had been at the surgery that day. Listening to his chest revealed widespread moist sounds over both lungs. 

I felt that Stuart almost certainly had bronchopneumonia. I rang the Repatriation hospital to arrange his admission and then arranged for urgent ambulance transport. Whilst waiting for the ambulance I gave him some fluid to drink and also some oxygen from a portable cylinder that I carry in the car. 

The following morning I had a call from the medical registrar at the hospital. The chest X-ray had confirmed a widespread pneumonia and Stuart was in intensive care having intravenous antibiotics and respiratory support. Despite his age and chronic lung problems they were hopeful that he would recover. 

A person with pneumonia is usually quite ill. The condition simply means an infection of one or both lungs. In pre- antibiotic days it was often fatal; even today it carries quite a risk, especially in elderly people, those whose immune systems are impaired, and in cases where the diagnosis is delayed. 

The main symptoms of pneumonia are fever, chills, and a heavy cough. There may also be shortness of breath and general symptoms like weakness, nausea and vomiting. Frequently it comes on quite abruptly; this may be the case in an otherwise well young adult who happens to develop pneumonia. 

There is also a group of atypical pneumonias. As the name suggests, these pneumonias do not play by the rules and often present in an unusual way. They tend to develop over several days and there is often a very persistent cough. A whole range of uncommon organisms can be responsible, including various animal-borne infections, the much-publicized Legionnaire's disease, and a condition called mycoplasma pneumonia. The recognition of atypical pneumonias like mycoplasma is important because the usual antibiotics for pneumonia have no effect at all, and the person may become very sick indeed if the correct antibiotic is not used. 

When pneumonia is suspected, a careful history is required. What is the general health like? Does the person smoke? Has there been a lot of sputum, or coughing up blood? In a child is there a possibility of an inhaled foreign body? What is the person's occupation? Has there been any recent travel overseas? Has there been contact with people who have TB? Does the person keep birds or other pets? 

Examination may reveal a high fever and perhaps some signs in the chest when listened to with a stethoscope. The diagnosis is usually confirmed with a chest X-ray. Sputum cultures may also be helpful to identify the organism responsible. Similarly, with atypical pneumonia blood tests may be necessary to find the precise cause. 

The treatment of pneumonia involves the use of antibiotics. If the person is quite sick or unable to take medication orally, admission to hospital is required. This allows intravenous antibiotics to be given and also makes it easier for chest physiotherapy, and the administration of oxygen should it be necessary. Any associated asthma requires treatment and frequently a respiratory specialist is involved in the management. 

More serious cases need very close monitoring in specialized respiratory or intensive care units. Measurements of the oxygen level in the blood gives an indication whether the patient will require respiratory assistance or ventilatory support. Fortunately, most cases respond very promptly to standard treatment with high-dose antibiotics. Follow-up chest X-rays are often performed to check that the infection has been completely cleared. 

Overwhelming cases of pneumonia still occur, even in people who have been previously well. Sometimes a viral infection like influenza is responsible. Because influenza is not treatable with antibiotics, annual immunization of at-risk groups is vitally important. In recent years a vaccine against pneumonia caused by the bacteria Strep. pneumoniae, or pneumococcus, has become available. The vaccine is called Pneumovax and it only needs to be given every five years. It is recommended for the same individuals who are most at risk from complications of the flu ie. people over 65 years, residents of nursing homes and chronic health care facilities, and for people of any age who have chronic illnesses like heart and lung disease. It is also recommended for people of any age who have had their spleen removed, for instance after trauma or surgery.

Pleurisy is a descriptive term that means the lining of the lung has become inflamed. This may occur in association with pneumonia. A typical pleuritic pain occurs with pleurisy; a catching or jabbing pain occurs on breathing, as the inflamed surface of the lung rubs against the inside of the chest wall. A scratchy, rubbing noise can often be heard when the chest is listened to with a stethoscope. Fortunately, pleurisy usually settles well once the underlying infection has been treated. 

Health Tip:
* Most coughs and colds blow over without even the need to see a doctor. However, symptoms like fever, persistent cough and shortness of breath should alert us to the  possibility of pneumonia.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001