Medically Fit For Exams
Medically Fit For Exams



  • Pneumonia is inflammation of the lower respiratory tract, and is characterised by visible changes on x-ray. It can be caused by a wide range of pathogenic organisms.


Risk Factors

  • Age (over 65 or under 2)
  • COPD
  • Cystic fibrosis, bronchiectasis, asthma
  • Immobility (eg bedbound, or spending time on the floor after a fall, post-stroke)
  • Mechanical ventilation (ie in ICU)
  • Immunosuppression (eg chemotherapy, HIV)
  • Smoking
  • Chronic gingivitis/poor dental hygeine


Differential Diagnoses

  • COPD
  • Asthma
  • Bronchiectasis
  • Pulmonary fibrosis
  • Lung cancer
  • Pulmonary oedema (eg from heart failure)



  • Worldwide disease burden is greater than HIV, malaria, cancer and heart attacks
  • Pneumonia is more common in the winter
  • US data:
    • Slightly higher incidence in males
    • Approx 20 deaths per 100,000 from pneumonia
    • 20% mortality in pneumococcal pneumonia
    • Pneumonia occurs in 9-27% of patients on ventilators, has mortality of 30-60%



  • Bacterial pneumonia is the most common, organisms listed in order of commonness:
    • Streptococcus pneumoniae/pneumococcus
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae (associated with bird/parrot handling)
    • Haemophilus influenzae – more common in children and young adults, can have complications of haemolytic anaemia, heptitis
    • Legionella pneumophilia (Legionnaire’s)
  • Viral causes of pneumonia include:
    • Influenza + common cold
    • Respiratory syncytial virus (RSV) is the most common cause of viral pneumonia in children < age 1
  • Fungal pneumonia is rare in the UK
    • Pneumocystis pneumonia (PCP) is associated with HIV infection, and is an AIDS defining illness. It is severe, and has a high mortality
  • Aspiration pneumonia is caused by an inhaled substance that leads to an inflammatory response rather than an infecting agent


Clinical Features

  • Fever
  • SOB, wheeze
  • Pleuritic chest pain
  • Cough, with yellow/green sputum
  • Reduced O2 sats/cyanosis
  • Tachypnoea + use of accessory muscles
  • Reduced air entry and dullness over affected area
  • X-ray changes (consolidation)
  • Confusion



  • Acute inflammatory response
    • Neutrophil infiltration into airspaces from capillaries
    • Production of ROS, digestive enzymes, phagocytosis of pathogen
    • Also results in damage to lung tissue – further inflammatory change
  • Increased mucus production



  • CXR
  • ABG
  • FBC + cultures
  • Sputum culture
  • U&Es
  • ECG
  • CT chest and bronchoscopy if indicated (rule out other causes)
  • CURB-65 score calculated
    • Confusion
    • Urea (raised)
    • Respiratory rate
    • Blood pressure
    • Age >65



  • Antibiotics – first dose within 4 hours of admission
  • Antipyretics and analgesia
  • O2 to maintain sats at 94-98% (88-92% if COPD)
  • Nebulisers/inhalers if needed
  • Fluids if hypotensive
  • Physiotherapy if sputum retention



  • 20% average mortality in pneumococcal pneumonia
  • Prognosis is poor in certain subgroups:
    • Advanced COPD
    • AIDS (especially if PCP)
    • Immunsuppressed
    • Advanced age: 38% mortality in over 80s (pneumococcal)
    • Ventilator-associated: mortality is 30-60%
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