Pneumonia Symptoms, Signs and Treatment

In 2017, over two million people died from pneumonia worldwide (Dadonaite & Roser 2019).

Respiratory illnesses, including pneumonia, remain a major concern to hospitals around the world, especially during the winter months when an influx of patients can put some hospitals into crisis mode.

Pneumonia ranges in severity from a mild illness to life-threatening. Anyone can contract pneumonia, but babies, young children and older people are particularly susceptible to the dangers of this illness (Healthdirect 2020).

Pneumonia is the leading infectious cause of death in children, with about 15% of deaths attributed to children under five (WHO 2019a).

There are multiple types of pneumonia: one of the most common and life threatening-types is pneumococcal pneumonia (Lung Foundation Australia 2020).

What is Pneumonia?

Pneumonia is an acute infection of the lungs that causes the alveoli in one or both lungs to fill with pus and fluids. This results in lung consolidation (wherein the alveolar spaces are filled with fluid instead of air) and interferes with gas exchange (Better Health Channel 2018; Moyer 2018).

When a person has pneumonia, breathing is painful and oxygen intake is limited (WHO 2019b).

Pneumonia doesn’t discriminate across the lifespan and can affect any age group, though it is more common in young children and older adults (Better Health Channel 2018). Depending on the severity, some people may not necessarily need to be hospitalised, whilst others will.

Generally, those with more comorbidities or any problem that may exacerbate pneumonia will require hospital admission. Pneumonia can also be treated in the community as long as the individual has access to good medical and nursing care.

How Serious is Pneumonia?

It is estimated that there are over 77,000 hospitalisations for pneumonia each year in Australia (Poulos et al. 2014).

There were 4,269 deaths caused by pneumonia and influenza in Australia in 2017, making it them 9th leading cause of death that year (ABS 2019).

Causes of Pneumonia

Pneumonia is caused by a viral, bacterial - or rarely - a fungal infection (Healthdirect 2020). In some cases, it is triggered by an existing cold or flu that enables pathogens to access the alveoli (Better Health Channel 2018).

Transmission commonly occurs by inhaling infected droplets in the air from a cough or sneeze of an infected person. It can also spread via blood (WHO 2019b).

Symptoms of Pneumonia

Symptoms may vary depending on age, the cause and severity of the infection, and any existing health problems (Better Health Channel 2018). Assessing the patient and gaining a comprehensive patient history is vital in diagnosis. Symptoms may include:

• Coughing (dry or productive);
• Fever, chills, or sweating;
• Breathing difficulties;
• Increased respiratory rate;
• Fatigue or general malaise;
• Little to no appetite;
• Chest pain;
• Abdominal pain or aches;
• Blue colouring around the mouth (cyanosis); and
• Nausea, diarrhoea, or vomiting.

(Health Direct 2018; Better Health Channel 2018; Healthy WA 2015)

With correct treatment, a health improvement is usually observed within 7 to 10 days (Better Health Channel 2018).

Symptoms of Pneumonia in Children

• Lethargy;
• Irritability;
• Chest pain;
• Abdominal aches or pain;
• Fever;
• Coughing and difficulty breathing;
• Little to no appetite; and
• Pallor.

(RCH 2018; Healthy WA 2015)

How is Pneumonia Diagnosed?

The following tests may be used to diagnose pneumonia:

• General examination;
• Nose and throat swab;
• Urine or sputum tests;
• Chest X-rays; and
• Blood tests.

(Healthdirect 2020; Better Health Channel 2018)

Who is Most at Risk of Pneumonia?

The following people are more likely to contract pneumonia and experience more severe symptoms:

• Infants and very young children;
• People over the age of 65 years;
• People who have had an organ transplant;
• People who have been hospitalised;
• First Nations peoples, particularly those with medical conditions or who live in remote communities;
• People with lung conditions including asthma, emphysema and cystic fibrosis;
• People with a chronic disease such as diabetes or cancer;
• People with a compromised immune system;
• People with feeding difficulties; and
• People who smoke.

(Healthdirect 2020; Healthy WA 2015)

Types of Pneumonia

Bacterial Pneumonia

• Presents with rust or green-coloured phlegm.
• Pneumococcal pneumonia is one of the most deadly forms of bacterial pneumonia. It is caused by the bacterium Streptococcus pneumoniae.
• Healthy people may carry Streptococcus pneumoniae in their nose and throat. It mostly does not cause illness, except in vulnerable groups.

(Lung Foundation Australia 2020; Better Health Channel 2018)

Viral Pneumonia

• Caused by several viruses (including influenza).
• Symptoms are flu-like.
• Responsible for roughly half of all pneumonia cases.

(Lung Foundation Australia 2020; Better Health Channel 2018)

Mycoplasma Pneumonia

• Caused by the bacterium Mycoplasma pneumoniae.
• Presents with white phlegm, vomiting and nausea.
• Pneumonia caused by mycoplasma organisms is often mild, but recovery may take longer.

(Lung Foundation Australia 2020; Better Health Channel 2018)

Fungal Pneumonia

• A less common type of pneumonia;
• Generally occurs in people with chronic health problems and/or vulnerable immune systems;
• Fungal pneumonia is caused by breathing in fungal spores.

(Lung Foundation Australia 2020; WebMD 2018)

There are other ways in which pneumonia may be classified or described:

• Depending on the part of the lung affected, e.g. bronchial pneumonia or lower lobe pneumonia;
• According to the organism causing the infection;
• Depending on whether the pneumonia is community-acquired or hospital-acquired (hospital-acquired pneumonia occurs after the patient has been admitted for over 48 hours);
• If it is aspiration pneumonia, which occurs as a result of aspiration, causing an inflammatory response in the affected area; and Whether it is ventilator-associated pneumonia.

(Dunn 2005; Farrell & Dempsey 2013)

How is Pneumonia Treated?

Antibiotics

Treatment depends on the severity of pneumonia. In mild cases, the individual may be able to take oral antibiotics in a community setting. For more severe cases, they may require admission to hospital and treatment with intravenous antibiotics, oxygen therapy and chest physiotherapy (Dunn 2005).

As pneumonia is an infection, antibiotic therapy should be started as soon as possible. Sometimes this can be before the causative organism has been determined, however, the type of antibiotic can be changed if necessary. Depending on the severity of pneumonia, this can be in either an intravenous or oral form (Watson 2008).

Oxygen Therapy

Another important aspect of pneumonia treatment is oxygen therapy and maintaining adequate oxygen saturation levels. Depending on the patient, oxygen saturation levels should be above 93%, with the oxygen concentrations also varying depending on the patient, their comorbidities and severity of pneumonia. Humidified oxygen therapy can also be used in order to assist the patient with expectoration (Watson 2008).

Sometimes pulse oximetry can be inaccurate on these patients, and this is where arterial blood gas levels may play a role in ensuring adequate oxygenation is being achieved. Some patients, even when receiving high flow oxygen, can still remain hypoxic, and therefore, continuous positive airway pressure may be indicated (Farrell & Dempsey 2013; Watson 2008).

Pain Management

It is important to remember that a patient with pneumonia may be in pain. This means that their lung expansion may be compromised, which can further exacerbate their condition. This pain can often be described as pleuritic-type chest pain (Farrell & Dempsey 2013; Watson 2008).

Those with severe pneumonia may require treatment from physiotherapists. As part of an interprofessional team, physiotherapists can assist in not only any concurrent physical decline and chest physiotherapy, but can also help teach the patient effective breathing patterns and posture to promote lung expansion and expectoration (Watson 2008).

Hydration

Other treatments for pneumonia should focus on ensuring the patient is adequately hydrated and if not, ensure that intravenous fluids are commenced. Adequate hydration is important for the expectoration of secretions and will also help with any associated hypotension. The individual may have increased fluid loss if they are febrile and continue to have an increased respiratory rate, therefore, urinary output should also be monitored, as this can flag deterioration in the patient’s condition (Dunn 2005; Watson 2008).

Nutrition

Another factor of treatment that can be easily overlooked is nutrition. People with severe pneumonia may be experiencing nausea and will therefore have a decreased appetite. Remember that when a person has an infection, their calorific requirements increase (Watson 2008).

Pneumonia Monitoring and Complications

Prompt and effective treatment of pneumonia is also essential in order to prevent complications from occurring. Possible complications include pleurisy, atelectasis, pleural effusion lung abscesses, bacteraemias, septicaemias and death. If the patient deteriorates and goes into respiratory failure, they may also require ventilation (Farrell & Dempsey 2013; Watson 2008).

Nurses need to ensure that regular monitoring of the patient occurs, including:

• Monitoring hydration and elimination;
• Observing vital signs including oxygen saturation;
• Providing oxygen therapy as needed;
• Ensuring the patient is positioned in a way that ensures adequate ventilation;
• Promoting rest and conservation of energy;
• Pressure area care;
• Mouth care;
• Monitoring and maintaining nutrition;
• Pain assessment and management;
• Educating the patient on infection control and hand hygiene; and
• Providing reassurance to the patient.

(Dunn 2005; Farrell & Dempsey 2013)

Pneumonia Prevention

Immunisation is a proven strategy for reducing the likelihood of contracting pneumonia (WHO 2019b; Lung Foundation Australia 2020) The pneumococcal vaccine is free under the National Immunisation Program (NIP) Schedule for certain groups of people (DoH 2020).

You should also advise patients to:

• Practice good hand hygiene to minimise the transmission of infection;
• Quit smoking and avoid smoking areas;
• Keep their immune system strong by maintaining a healthy diet, exercising and getting sufficient sleep

(Lung Foundation Australia 2020; Mayo Clinic 2020)

Conclusion

Nurses contribute to all phases of an individual’s pneumonia journey and are vital in ensuring they receive the holistic care they need during this illness.

Additional Resources

• Common Respiratory Tract Infections (RTI)
• Hand Hygiene 101
• Infectious Diseases: How Do You Break the Chain?

References

• Australian Bureau of Statistics 2019, 3303.0 - Causes of Death, Australia, 2017, ABS, viewed 3 December 2020, https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2017~Main%20Features~Australia's%20leading%20causes%20of%20death,%202017~2
• Australian Government Department of Health 2020, Pneumococcal Immunisation Service, DoH, viewed 3 December 2020, https://www.health.gov.au/health-topics/immunisation/immunisation-services/pneumococcal-immunisation-service-0
• Dadonaite, B & Roser, M 2019, Pneumonia, Our World in Data, viewed 3 December 2020, https://ourworldindata.org/pneumonia
• Dunn, L 2005, ‘Pneumonia: Classification, Diagnosis and Nursing Management’, Nursing Standard, vol. 19, no. 42, pp. 50-54, https://journals.rcni.com/nursing-standard/pneumonia-classification-diagnosis-and-nursing-management-ns2005.06.19.42.50.c3901
• Farrell, M & Dempsey, J (eds) 2013, Smeltzer and Bare’s Textbook of Medical-Surgical Nursing, 3rd edn, Lippincott Williams and Wilkins, Broadway.
• Healthdirect 2020, Pneumonia, Healthdirect, viewed 3 December 2020, https://www.healthdirect.gov.au/pneumonia
• Healthy WA 2015, Pneumonia, Healthy WA, viewed 3 December 2020, https://healthywa.wa.gov.au/Articles/N_R/Pneumonia
• Mayo Clinic 2020, Pneumonia, Mayo Clinic, viewed 3 December 2020, https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204
• Moyer, N 2018, Lung Consolidation: What it is and How it’s Treated, Healthline, viewed 3 December 2020, https://www.healthline.com/health/lung-consolidation#vs.-pleural-effusion
• Poulos, L M, Correll, P K, Toelle, B G, Reddel, H K, and Marks, G B 2014, Lung Disease in Australia, Woolcock Institute of Medical Research, viewed 3 December 2020, https://www.cesphn.org.au/preview/chronic-disease-management-1/respiratory-1/1851-lung-disease-in-australia-report-final-22october14/file
• The Royal Children's Hospital Melbourne, Pneumonia, RCHM, viewed 3 December 2020, https://www.rch.org.au/kidsinfo/fact_sheets/Pneumonia/
• Watson, D 2008, ‘Pneumonia 2: Effective Nursing Assessment and Management’, Nursing Times, vol. 104, no. 5, pp. 30-31, https://www.nursingtimes.net/clinical-archive/respiratory-clinical-archive/pneumonia-2-effective-nursing-assessment-and-management-05-02-2008/
• WebMD 2018, Types of Pneumonia, WebMD, viewed 3 December 2020, https://www.webmd.com/lung/pneumonia-types#2
• World Health Organisation 2019a, Pneumonia, WHO, viewed 3 December 2020, https://www.healthdirect.gov.au/pneumonia
• World Health Organisation 2019b, Pneumonia, WHO, viewed 3 December 2020, https://www.who.int/news-room/fact-sheets/detail/pneumonia