What types of pneumonia are there?
If a person gets pneumonia outside the hospital, then the pneumonia is called community-acquired.
Nosocomial pneumonia, on the contrary, develops in hospitals and nursing homes. This also includes pneumonia associated with mechanical ventilation.
Dividing the disease according to its origin helps to select the necessary antibiotics in the first hours of the disease.
The more areas of the lungs are affected by inflammation, the more dramatic the development of pneumonia. Depending on the location of the zones of inflammation, there are unilateral, bilateral, polysegmental, and lobar.
“Atypical” and “typical” pneumonia
Any pneumonia is dangerous if it is not detected in time and the correct treatment is not prescribed. The word “atypical” stuck after the emergence of SARS in 2003. This pneumonia required completely different treatment. In atypical pneumonia, complaints and symptoms may differ from classic pneumonia - not a high temperature, the symptoms are more similar to ARVI.
Typical pneumonia is caused by “classical” pathogens. These include Streptococcus pneumonia (pneumococcus), as well as Haemophilus influenza (hemophilus influenzae).
Non-classical microorganisms cause atypical pneumonia. For example, Legionella, Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Coxiella burnetiid.
Pneumonia caused by respiratory viruses are grouped separately - Influenza A, Influenza B, Rhinoviruses, Parainfluenza, Adenovirus, Respiratory syncytial virus, Metapneumovirus, Coronaviruses (SARS Cov-1, SARS Cov-2, MERS).
The differences between “atypical” and “typical” are relative. If you take an x-ray of the lungs, it is possible to assume an atypical pathogen based on the characteristics of the obtained x-ray.
Prevention of pneumonia
To avoid developing pneumonia, you should regularly follow these recommendations:
- observe the rules of personal hygiene - do not eat or touch your face and mouth with unwashed hands;
- Perform light physical activity every day, do exercises, or walk a lot in the open air;
- eat food enriched with fiber, vitamins and minerals (especially during an epidemic);
- rest regularly, avoid stress if possible, maintain a daily routine;
- ventilate the room several times a day;
- harden the body (just not during any illness);
- get rid of bad habits, especially smoking, as this bad habit increases the risk of developing pneumonia;
- during seasonal epidemics, it is necessary to avoid public places with large crowds of people;
- do not overcool or overheat the body;
- Get vaccinated if possible.
Timely contact with a competent specialist guarantees the absence of secondary diseases in the future. Pulmonologists at the Yusupov Hospital will ensure a quick recovery for the patient, protecting him as much as possible from the development of complications. You can see a doctor by first scheduling a consultation on our clinic’s website or by calling.
What determines the severity of pneumonia?
- Pneumonia may be limited to fever, cough with sputum without breathing problems. This is a mild form description.
- Severe course is manifested by respiratory disorders, multiple organ failure, and sepsis.
- A person's immune response determines the extent of lung damage. The more massive the response, the more severe the disease.
- Obesity, chronic heart and lung diseases, and diabetes worsen the prognosis of the disease.
Who gets pneumonia more often?
- The older a person is, the higher the risk of disease.
- Patients suffering from COPD, bronchiectasis, asthma, chronic heart disease (heart failure), stroke, diabetes.
- A previous viral infection (ARVI) provokes bacterial or fungal pneumonia.
- Smoking and excessive alcohol consumption contribute to the disease
- Other lifestyle factors - such as prisons, homeless shelters, exposure to environmental toxins (such as solvents, paints, or gasoline)
Management of patients with CAP in outpatient settings
For mild pneumonia, antibacterial treatment of adults and children can be completed with stable normalization of body temperature for 3–4 days (total course duration 7–10 days). If there is clinical/epidemiological evidence of mycoplasma or chlamydial infection, the duration of therapy should be 14 days. An initial assessment of the effectiveness of therapy should be carried out 48–72 hours after the end of the course of treatment (re-examination). If symptoms persist or progress, it is necessary to reconsider the tactics of antibacterial therapy and re-evaluate the advisability of hospitalization.
According to the recommendations of the Russian Respiratory Society, outpatient patients are divided into 2 groups, differing in etiological structure and tactics of antibacterial therapy (see Table 1. Antibacterial therapy of CAP in outpatients):
Table 1.
Antibacterial therapy of CAP in outpatients
| Group | Most common pathogens | Drugs of choice | Alternative drugs | Patient characteristics |
| Mild CAP in patients under 60 years of age without concomitant pathology | S. pneumoniae M. pneumoniae C. pneumoniae H. influenzae | Amoxicillin orally or macrolides (azithromycin, clarithromycin) orally | Respiratory fluoroquinolones (levofloxacin, moxifloxacin) orally | |
| Mild CAP in patients over 60 years of age and/or with signs of concomitant pathology | S. pneumoniae C. pneumoniae H. influenzae S. aureus Enterobacteriaceae | Amoxicillin + clavulanic acid or Amoxicillin + sulbactam orally | Respiratory fluoroquinolones (levofloxacin, moxifloxacin) orally | Concomitant diseases affecting etiology and prognosis: COPD, diabetes, congestive heart failure, liver cirrhosis, alcohol abuse, drug addiction, exhaustion |
Symptoms and signs of pneumonia
Complaints with pneumonia are sudden. Fever, chills, fatigue, chest pain combined with cough (with or without phlegm), shortness of breath, difficulty breathing, increased breathing occur and increase over several hours.
Blood tests will help diagnose the disease: leukocytosis or leukopenia is the result of the body's inflammatory response. Inflammatory markers such as ESR, C-reactive protein and procalcitonin may increase, although the latter is largely specific to bacterial infections.
A mandatory test for diagnosing pneumonia is chest x-ray.
Clinic
The main symptoms of pneumonia, which appear in both adults and children.
- Fever: occurs acutely, quickly reaches febrile levels
- Cough with copious discharge of purulent sputum; there may also be blood in the sputum (especially in the case of lobar pneumonia)
- Chest pain associated with breathing
- Shortness of breath, feeling of lack of air
- Manifestations of intoxication: severe weakness, fatigue, sweating, nausea, vomiting
- In the case of “atypical” pneumonia (Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae, Pneumocystis jirovecii), there may be a gradual onset with a dry, unproductive cough, not without common symptoms - pain and sore throat, weakness, malaise, myalgia, headaches, pain in the abdomen - with minimal changes on the x-ray
- Elderly patients often have more severe general symptoms: drowsiness, confusion, anxiety, sleep disturbances, loss of appetite, nausea, vomiting, signs of exacerbation/decompensation of chronic diseases
Pneumonia due to COVID 19 infection.
The course of the disease does not go beyond the general concept of pneumonia. Classic symptoms are present: fever, chills, muscle pain, cough.
80% suffer from pneumonia without breathing problems and at home.
20% have severe manifestations of the disease: breathing is difficult, the person begins to breathe quickly, and there is a need to use additional oxygen. If it worsens, failure of important organs such as the heart and kidneys may occur. The longer the patient is in the hospital, the greater the likelihood of hospital infections and fungi.
Is hospitalization necessary for COVID 19 pneumonia?
No, hospital treatment is not always required.
Outpatient treatment is possible for patients with mild pneumonia. Patients who are initially healthy, with normal breathing, and without concomitant diseases are treated at home.
Hospitalization is necessary for patients whose oxygen saturation is less than 94% and who are breathing rapidly.
I feel like I'm having trouble breathing. Am I having respiratory failure?
The easiest way to understand that you are developing respiratory failure is to count your “inhalation and exhalation” per minute. If more than 21, then you should call a doctor. Another way is to measure the oxygen in your blood. Many people already have a pulse oximeter at home. With this device you can monitor saturation - if it is below 94%, then regard this situation as a deterioration and seek help from doctors.
Diagnostics
If pneumonia is suspected, a comprehensive diagnosis is important:
- X-ray of the lungs. Recommended both in cases of suspected disease and a month after treatment. X-ray allows you to see parenchymal (focal, diffuse) darkening and examine the pulmonary pattern (with infiltration it is enhanced).
- X-ray computed tomography of the chest. Most often it is prescribed if an X-ray of the lungs does not show the dynamics, and for some reason the treatment does not help the patient, or it is important for the doctor to examine the patient’s lungs in those sections in which they are poorly visible on the X-ray.
- Laboratory diagnostics. A complete blood count (especially leukocytes), a biochemical blood test and a sputum test play an important role.
- Bronchospokia. Endoscopic method. It is used if you need to find out whether it really is pneumonia or an anatomical anomaly of the lung, a foreign object in the respiratory tract, or a tumor.
In some cases, an ultrasound of the heart is additionally performed. Especially if there is a suspicion that not only the lungs are inflamed, but also the heart muscle.
The use of CT in the diagnosis of viral pneumonia.
Computed tomography has high sensitivity compared to radiography and detects changes in the lungs at the initial stages of the disease earlier than the results of laboratory tests.
- The advantage of the method is that it detects changes in the lungs even in people infected with COVID-19, but who have no symptoms of infection.
- Despite its high sensitivity, CT cannot give an accurate answer about the causes of pneumonia (bacteria, viruses, fungi).
What is “ground glass” in a CT scan?
Densification of the lung tissue “frosted glass” is the initial phase of pneumonia. Occurs when the alveoli gradually fill with fluid.
When the bronchi and alveoli fill with fluid, areas of compaction will appear, which are called consolidation. Consolidation of lung tissue occurs during a prolonged inflammatory process.
I have COVID 19 and CT-2 What does this mean?
It is important to understand how much lung tissue is affected. The more the lung tissue is involved in inflammation, the more difficult it is to obtain oxygen from the inhaled air. Without oxygen, a person quickly dies. For example, with pneumonia caused by COVID 19, it takes several hours for the lungs to worsen. The sooner a decision is made about hospitalization, oxygen therapy and treatment, the greater the chance of recovery.
To assess changes, the percentage of lungs damaged by pneumonia is calculated. The measurement is carried out “by eye”. The obtained result is compared with the scale of prevalence of changes:
- CT-0 – no signs of pneumonia
- KT-1 – up to 25%
- KT-2 – from 25 to 50%
- KT-3 – from 50 to 75%
- KT-4 – over 75%
The percentage score sorts patients who urgently require hospital treatment from those who can be treated at home.
If your CT scan is 2, this corresponds to mild pneumonia. Such changes are not accompanied by difficulty breathing and do not require hospitalization. But CT 2 can, if treated incorrectly, turn into CT 3 and 4. Therefore, supervision by a doctor is mandatory!
If the doctor does not hear wheezing in the lungs when listening, does that mean I do not have pneumonia?
This is not true. Diagnosis requires demonstration of changes in lung tissue on radiography (CT) and clinical manifestations (eg, fever, shortness of breath, cough and sputum production), changes in blood tests.
Management of patients with CAP in a hospital setting
It is advisable to begin therapy for pneumonia in hospitalized patients with parenteral antibiotics. After 3–4 days, provided the temperature normalizes, intoxication and other symptoms decrease, it is possible to switch to oral forms of antibiotics until the course of treatment is completed (step-down therapy). Antibacterial drugs can be used both as part of combination therapy and as monotherapy. More detailed treatment regimens for CAP are presented in Table No. 2.
Table 2.
Treatment regimens for CAP depending on the course
| Group | Most common pathogens | Recommended treatment regimens | |
| Drugs of choice | Alternative drugs | ||
| EP of non-severe course | S. pneumoniae H. influenzae C. pneumoniae S. aureus Enterobacteriaceae | Benzylpenicillin IV, IM ± macrolide (clarithromycin, azithromycin) orally, or Ampicillin IV, IM ± macrolide orally, or Amoxicillin + clavulanic acid IV ± macrolide orally, or Cefuroxime IV, IV m ± macrolide orally, or Cefotaxime IV, IM ± macrolide orally, or Ceftriaxone IV, IM ± macrolide orally | Respiratory fluoroquinolones (levofloxacin, moxifloxacin) IV Azithromycin IV |
| Severe EP | S. pneumoniae Legionella spp. S. aureus Enterobacteriaceae | Amoxicillin + clavulanic acid IV + macrolide IV, or Cefotaxime IV + macrolide IV, or Ceftriaxone IV + macrolide IV | Respiratory fluoroquinolones (levofloxacin, moxifloxacin) IV + III generation cephalosporins IV |
Note:
- If the presence of “atypical” pneumonia is suspected, the use of macrolides is indicated.
- If there is a risk of infection with P. aeruginosa (bronchiectasis, use of corticosteroids, therapy with broad-spectrum antibiotics for more than 7 days during the last month, exhaustion), the drugs of choice are ceftazidime, cefepime, cefoperazone + sulbactam, meropenem, imipenem, piperacillin/tazobactam, ciprofloxacin, in monotherapy or in combination with aminoglycosides of the II–III generation.
- If aspiration is suspected, the following treatment options are indicated: cefoperazone + sulbactam, ticarcillin + clavulanic acid, carbapenems, piperacillin/tazobactam.
An initial assessment of the effectiveness of antibacterial therapy should be carried out 24–48 hours after the start of treatment. If signs of pneumonia persist in adults or children, treatment tactics should be reconsidered.
For mild CAP, the course of antibiotic therapy is about 7–10 days. For severe CAP of unspecified etiology, a 10-day course of antibiotic therapy is recommended. If there is evidence of mycoplasma or chlamydial etiology, therapy should last 14 days; in the case of CAP caused by staphylococci, gram-negative enterobacteria, legionella, the duration of therapy is 14–21 days.
In addition to antibiotics, the following are used in the treatment of CAP:
- Antiviral therapy: neuraminidase inhibitors (oseltamivir, zanamivir), active against influenza A and B viruses. Duration of use is 5–10 days.
- Mucolytics and expectorants - tablet or inhalation forms.
- Glucocorticosteroids: used for developed septic shock (hydrocortisone 200–300 mg/day for no more than 7 days).
- Oxygen therapy for PaO2 < 55 mm Hg. Art. or SpO2 < 88% (breathing air). It is optimal to maintain SpO2 within 88–95% or PaO2 within 55–80 mm Hg. Art.
- Infusion therapy - to correct hypovolemia.
- Low molecular weight heparins for the prevention of thromboembolism in severe patients.
- Physiotherapy and exercise therapy to reduce inflammation and improve sputum discharge.
Treatment of pneumonia
To treat pneumonia, you need to know the name of the infection. In patients, the name of the pathogen is unknown at the very beginning of the disease, so empirical antibiotic therapy is used - treatment aimed at the likely pathogen. For all patients with CAP, treatment regimens have been developed aimed at destroying S.pneumoniae and atypical pathogens.
For most patients, combination therapy with beta-lactam antibiotics or macrolides is used. Alternative regimens include fluoroquinolone monotherapy.
Treatment of SARS CoV-2
- The principles of treating pneumonia are general. Prescription of antiviral and antibacterial therapy.
- In severe cases, in a hospital setting, high-flow oxygen therapy, monoclonal antibodies, anticoagulants, and pulmonary ventilation are prescribed.
- Antibiotics do not work against the COVID 19 virus.
Modern classification of community-acquired pneumonia:
- By pathogenesis:
a. Primary - pneumonia that developed as an independent disease
b. Secondary - pneumonia that develops against the background of another disease, such as influenza
- By localization:
a. Unilateral (left-sided and right-sided pneumonia)
b. Double-sided
- Based on the volume of tissues involved in inflammation, the following types of pulmonary pneumonia in adults and children are distinguished:
a. Focal - a small focus of inflammation (bronchopneumonia - with damage to the bronchi and respiratory sections)
b. Segmental - involving one or more segments of the lung
c. Lobar - with damage to the lobe of the lung (lobar pneumonia - with damage to the alveoli and part of the pleura)
d. Confluent - when lesions merge into larger ones
e. Total - damage to the entire lung
- Depending on the etiology and characteristics of the patient:
a.
Typical (in patients without severe immune disorders):- Bacterial
Viral pneumonia
- Fungal
- Mycobacterial
- Parasitic
- In patients with acquired immunodeficiency syndrome
- In patients with other diseases and pathological conditions
b. In patients with severe immunocompromise :
c. Aspiration pneumonia/lung abscess/pneumonia (one lung)
Rehabilitation after pneumonia
In addition to drug therapy aimed at bacteria, virus and inflammation, it is necessary to restore lung function to its original healthy level.
After an illness, changes form in the lungs. This includes “frosted glass” and fibrosis of the lung tissue, pneumofibrosis. In these areas, gas exchange is difficult, the nutrition of the alveoli and bronchi is disrupted, and the protection of the bronchi is reduced. Infection and pneumonia affect a person at the same time, depriving him of strength, confidence, and reducing the quality of life. Efforts must be made to prevent fibrotic changes in the lungs. The problem is solved by a rehabilitation program consisting of a set of medical procedures, inhalations, breathing simulators, and physical therapy exercises.
More about rehabilitation
Our specialists
Chikina Svetlana Yurievna
Candidate of Medical Sciences, pulmonologist of the highest category. Official doctor, expert at Russian congresses on pulmonology.
30 years of experience
Kuleshov Andrey Vladimirovich
Chief physician, candidate of medical sciences, pulmonologist, somnologist, member of the European Respiratory Society (ERS).
Experience 26 years
Meshcheryakova Natalya Nikolaevna
Candidate of Medical Sciences, pulmonologist of the highest category, associate professor of the Department of Pulmonology named after. N.I. Pirogov.
Experience 26 years
Nikitina Natalia Vladimirovna
Deputy chief physician, pulmonologist, allergist of the highest category. Full member of the European Academy of Allergy and Immunology.
Experience 15 years
