Pneumonia, winter problem. 18 questions and answers.

1. What exactly is pneumonia?

An infection of the alveoli. A person has millions of alveoli, which are located deep in the lungs. The vesicles take in oxygen from the air and release carbon dioxide from the blood. Without protection, all kinds of pathogens would enter the lungs when inhaled and could infect the alveoli. Fortunately, the body has a natural defense mechanism: the cilia on the inside of the airway. They carry what does not belong there with a little mucus to the oral cavity, after which you swallow it.

However, sometimes those cilia don’t work as well. This may be due to a lung condition, such as COPD or asthma. The cilia can also become weakened if a person is otherwise in fragile health, has a viral infection, takes immunosuppressant drugs, or smokes. Disease-causing bacteria then penetrate more easily into the deeper alveoli. The warm and moist tissue there is an ideal environment for germs to multiply. The body reacts with a violent immune response: pneumonia develops. Sometimes that inflammation is in part of the lung, sometimes in an entire lung, sometimes in both. In the latter case we speak of double pneumonia.

2. What are the main complaints?

Cough, fever and rapid, shallow breathing. Often a patient also coughs up yellow or green mucus and has pain when taking a deep breath or coughing. Sometimes there is a headache, loss of appetite or a blue discoloration of fingers, feet and lips. In very old people – the most vulnerable group – the symptoms are often less clear, making pneumonia sometimes difficult to recognize.

3. Is it common?

Very often. In 2007, general practitioners diagnosed pneumonia more than 172,000 times. Men get pneumonia slightly more often than women, especially in old age. Why is unknown. About 30,000 people with pneumonia are hospitalized every year. According to Statistics Netherlands, that number has risen sharply since the 1980s. For example, the number of hospitalizations of people over 65 with pneumonia tripled between 1981 and 2005. This probably has to do with the aging population and the fact that diseases such as diabetes or cancer are increasingly treatable. Patients live longer, but their fragile health makes them extra susceptible to pneumonia.

4. Can you get pneumonia from the flu?

Of course. Flu is caused by a virus. Usually a virus infection is not serious, but the flu virus can cause a temporary weakening of the cilia in the trachea. Sometimes pneumonia develops on top of the flu, usually due to a bacterium that sees its chance and strikes.

5. What else can make you get pneumonia?

Bacteria are the most common cause of pneumonia. There are hundreds of different ones, but in adults the pneumococcus is especially common. Another initiator, the legionella bacterium, can lead to a serious form of pneumonia, known as Legionnaires’ Disease.

In addition to inhaling them, bacteria can also enter the lungs through the pharynx, for example when choking. Or with a partial blockage of the airway, for example due to a tumor, which sometimes hinders the clearing of bacteria from the lungs. The same danger exists after surgery, if the coughing is painful, leaving mucus in the lungs as a result. Finally, you can contract bacterial pneumonia if an infection elsewhere in the body, for example from a heart valve, spreads through the bloodstream to the lungs.

Examples of viruses that can cause pneumonia include chickenpox and SARS. In rare cases, a flu virus can directly cause pneumonia. In addition to viruses and bacteria, fungi can also lead to pneumonia. This generally only happens in people who have a severely disrupted immune system, for example in patients with AIDS or leukemia.

6.Is pneumonia contagious?

That depends on the cause. The most common pathogen, pneumococcus, is probably not very contagious. Doctors do not yet know how this bacteria is transferred from one person to another, but the chance that you ‘infect’ someone with it is not very high. Tuberculosis (TB) is a highly contagious form of pneumonia. Fortunately, TB is very rare in the Netherlands.

7. Why are the elderly in particular at high risk?

Pneumonia mainly affects people with a weakened immune system. These are very young children, really old people and/or patients with conditions that weaken the (lung) defense system, such as cardiovascular disease, diabetes, COPD lung disease or cancer.

8. Are there any other risk factors?

The flu, certain medicines, excessive alcohol consumption and being underweight also cause a lower resistance. The same goes for smoking. This also damages the cilia in the windpipe. Poor dental care can cause bacteria to accumulate in the mouth and pharynx and from there into the lungs.

9. Is there a higher risk of pneumonia in winter?

Yes, pneumonia is much more common in the winter than in the summer. The cold can irritate the nasal mucosa, which means that certain viruses can get a hold of it more quickly. Then bacteria can easily enter.

10. Is it true that some drugs increase the risk of pneumonia?

That’s right, but the risks are small. A well-known example is antacids. Reduced acidity in the stomach would make bacteria more likely to spread from there to the lungs. However, this is a very small increase in risk.

With antidepressants and antipyscotics, the risk may be slightly higher, but also small. Such drugs can lead to drowsiness and muscle stiffness, which may cause users to choke more often. For both antacids and psychiatric drugs, the benefits usually outweigh these drawbacks.

Some drugs that suppress the natural defenses significantly increase the risk of some special forms of pneumonia. For example, some anti-rheumatic drugs increase the risk of tuberculosis, a contagious form of pneumonia. Patients who receive certain anti-rejection drugs after a transplant are more likely to develop a variant of pneumonia called PCP.

11. How Is Pneumonia Treated?

Most pneumonias are mild and are treated by the general practitioner. He or she prescribes an antibiotic, such as amoxicillin, which quickly kills the most common pathogen – pneumococcus. Normally, the complaints should disappear within two to four weeks. Patients are referred to the hospital if the complaints are more severe and/or the patient has underlying health problems. In the hospital, different types of antibiotics are administered by IV, possibly supplemented with fluids and oxygen. If the situation is very serious, it may be necessary to give a patient a ventilator in the intensive care unit.

12. What can be the consequences of pneumonia?

Most people have no permanent damage from pneumonia. Patients treated in intensive care may initially experience complications, but these, too, usually disappear after a year. Pneumonia can have serious consequences if the disease results in blood poisoning. This happens when bacteria spread from the lungs through the bloodstream to the rest of the body. In such a situation, the complications follow each other quickly, possibly resulting in death. Even people who are already in poor health sometimes do not survive pneumonia. About 5,500 people die of pneumonia every year in the Netherlands.

13. When is it wise to go to the doctor?

Certainly if you belong to one of the risk groups, you should not wait too long. Pneumonia can start insidiously, but get worse very suddenly. Sometimes it’s a matter of hours. The trouble is that the complaints are often vague. Not all patients with pneumonia, for example, cough, especially very old people. It can therefore take a long time before someone calls in the GP or makes the correct diagnosis for the GP.
The sooner you catch it, the less likely the infection will cause irreparable damage.

14. How is the diagnosis made?

In most cases, this is done on the basis of a physical examination and the patient’s story. In the case of more serious complaints, coughed up mucus can be examined in the laboratory or a lung x-ray can be made in hospital.

15. You often hear that patients who are already in the hospital get pneumonia there. How is that possible?

Because of their fragile health, hospital patients are extra sensitive to certain pathogens they already carry. Harmful gut bacteria, for example. They can work their way up and get into the lungs. When a patient is on a ventilator, bacteria sometimes penetrate from the throat into the lungs.

16. What if you contracted pneumonia abroad?

After returning home, be extra alert for complaints, even if the pneumonia has already been treated there. Many more antibiotics are prescribed in countries such as Greece, Spain, South Africa and the United States than here. As a result, some variants of the pneumococcal bacteria have become resistant to certain drugs. A standard course of antibiotics does not help against such a foreign pneumonia. Fortunately, the percentage of pneumococcal bacteria that do not respond to antibiotics in the Netherlands is still very low.

17. Can you be vaccinated against pneumonia?

Against the most common cause, the pneumococcal bacteria, yes. Children are vaccinated against it as standard. Many elderly people in fragile health are also offered such a vaccination. Mind you, that’s not the same as the flu shot. A large-scale study is currently being carried out in the Netherlands to see whether it makes sense to vaccinate all elderly people against pneumococci. Incidentally, a vaccination does not offer a 100 percent guarantee; a vaccination never protects against all variants of a bacterium. In addition, there are other pathogens that can cause pneumonia.

18.What can you do yourself to prevent pneumonia?

Besides keeping an eye on your general health by eating a healthy diet and getting enough exercise, the most important piece of advice is: don’t smoke. Cigarettes are major culprits, even when it comes to pneumonia. It is wise for people in fragile health to be vaccinated against the flu and pneumococcus annually.

With thanks to Prof. Tjip van der Werf, pulmonologist at the University Medical Center Groningen (UMCG).