Guide to Pneumonia

Pneumonia is a common and serious infection that affects millions of people worldwide every year. In the U.S., pneumonia is the 2nd leading cause of hospital admission in adults behind childbirth resulting in at least 1 million hospital admissions every year. Among infectious diseases, it is the most common cause of death resulting in approximately 50,000 deaths per year. Due to its potential complications, cases of pneumonia can lead to lengthy hospitalizations. Even in otherwise healthy people, pneumonia recovery can take almost a month, and for seniors, this time frame can be much longer. By the end of this article, you’ll have a much better understanding of pneumonia, and how to best provide care to yourself or loved one.

Types of pneumonia

Not all cases of pneumonia are the same. Pneumonia can be caused by a number of factors and treatment and recovery time may vary depending on the cause and the individual. There are more than 30 causes of pneumonia which are normally grouped into 3 main categories of pneumonia: bacterial, viral, and mycoplasma.

Bacterial pneumonia

Bacterial pneumonia is caused by bacterial strains that make their way into the lungs. It is generally treated with a course of antibiotics. This type of pneumonia is often seen in people with already weakened health. Some risk factors for developing bacterial pneumonia include:

  • Smoking
  • Advanced age
  • Poor nutrition
  • Alcohol abuse
  • Drug use
  • Immobility or limited mobility
  • Recent surgery
  • Other illnesses
  • A compromised immune system
  • A respiratory condition such as asthma or chronic obstructive pulmonary disease (COPD)

Bacterial pneumonia causes the lungs to become inflamed and filled with cell debris, pus, and other fluids. This makes it difficult for the lungs to work properly leading to difficulty breathing, chest pain, fevers up to 105 degrees Fahrenheit, and confusion, especially in seniors. Other common symptoms of bacterial pneumonia include:

  • Rapid pulse
  • Shaking
  • Muscle pain
  • Loss of appetite
  • Exhaustion
  • Pale skin
  • Sweating
  • Yellow or green mucus produced by coughing
  • Blue tint to the lips and fingertips

Viral pneumonia

Viral pneumonia is caused by a virus such as influenza infecting the lungs. Viral pneumonia can lead to the development of bacterial pneumonia and often has many of the same initial symptoms of pneumonia. Most commonly a dry cough, headache, and muscle pain also develop with viral pneumonia. Unlike bacterial pneumonia, viral pneumonia cannot be treated with antibiotics. It is often treated with rest, fluids, and medications to help with coughing and other pneumonia symptoms.

Mycoplasma pneumonia

Mycoplasma pneumonia, sometimes called “atypical” or “walking” pneumonia, is also caused by bacteria but is significantly more mild than other forms of pneumonia. This is more likely to be seen in children with pneumonia and younger adults and is more contagious than other types of pneumonia. Due to its contagious nature, it is often found in crowded places such as schools, nursing homes, community centers, and college dorms. Many people who get this milder form of pneumonia recover on their own without antibiotics or other interventions.

Other common types of pneumonia include:

Aspiration pneumonia and dementia

Aspiration pneumonia is caused when food, beverages, saliva, or vomit are inhaled into the lungs. When the body is unable to cough up the foreign substance, a lung disease or infection occurs. This can occur in people who are having difficulty swallowing such as patients recovering from a stroke or major injury. It may also occur in patients with advanced dementia, brain damage, or other cognitive issues who may no longer have a reliable gag reflex. While relatively rare in other populations, aspiration pneumonia is much more common in individuals with dementia. In fact, pneumonia is the cause of death listed on the death certificates of up to two-thirds of individuals with dementia.

Diagnosis of pneumonia

Diagnosis of pneumonia is sometimes performed through a simple physical exam, discussion of pneumonia symptoms, and a review of any recent health conditions such as an illness or surgery. During the physical exam, a physician will listen to the chest for air movement in and out of the lungs as well as for any abnormal breath sounds.

Several tests may be performed to confirm a diagnosis of pneumonia including a:

  • Chest x-rays

Chest x-rays take pictures of the inside of the lungs allowing the physician to see any inflammation.

  • Chest CT scan

A CT scan is used to view the lungs in greater detail than can be seen on an x-ray.

  • Sputum culture

A sputum culture is a test of mucus that has been coughed up. This is done to check for bacteria.

  • Bronchoscopy

The bronchi are the largest airways in the lungs. With a bronchoscopy, a tube is put down the large bronchi of the lungs to check for any blockage and inflammation.

  • Pulse oximetry monitoring

Pulse oximetry monitors the amount of oxygen in the blood.

  • Blood tests

Blood tests may be used to determine if the infection has spread to the bloodstream and to check the amount of oxygen in the blood.

  • Pleural fluid culture

There is a very thin, fluid-filled membrane around each lung that contains pleural fluid. In a pleural fluid culture, a needle is used to remove some fluid from this space and the fluid is tested for bacteria.

Treatment of pneumonia

The treatment of pneumonia will depend on the type of pneumonia, the severity of the infection, and the general health of the patient prior to contracting pneumonia. In addition to antibiotics, a physician will recommend several steps that your family member needs to take to treat pneumonia at home.

They will need to drink plenty of fluids which will help liquefy the mucus in their lungs so it may be coughed up more easily. They will need to get plenty of rest. They will also likely be advised to take an anti-inflammatory medication such as aspirin, acetaminophen, or ibuprofen to control their fever if they have one. They will likely be advised not to take a cough medication unless their cough is severe or keeping them awake at night because coughing helps the body fight the infection and bring up phlegm and mucus from the lungs. These steps will help most people recover from pneumonia in approximately 1 to 3 weeks.

If antibiotics have been prescribed and are not helping or if your family member’s symptoms of pneumonia are severe or worsen, they may be admitted to a hospital for treatment. While in hospital, they may be prescribed a stronger dose of antibiotics which may be administered intravenously (IV). They may also receive respiratory tract treatments, oxygen, IV fluids and physical therapy to their chest to try to loosen secretions in the lungs.

Complications of pneumonia

For many people, pneumonia is treated effectively with no additional complications. However, in individuals with previously compromised immune systems, seniors, very young children, and individuals with pre-existing respiratory conditions, there is an increased risk of complications including:

  • Respiratory failure

Respiratory tract failure requires the use of a breathing machine called a ventilator. Patients in respiratory failure are often admitted to an intensive care unit (ICU) where they may be monitored while on a ventilator. This complication usually results in a much longer recovery time.

  • Acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is a severe and sudden form of respiratory failure that may be fatal.

  • Lung abscesses

Pockets of pus that form inside or around the lungs are known as lung abscesses. These may need to be drained surgically or through the insertion of chest tubes.

  • Sepsis

Sepsis is a serious condition that may occur when the body tries to fight an infection by releasing chemicals into the bloodstream. Sepsis is very dangerous and may cause organ and multiple system failures leading to death. Pneumonia is the most common cause of sepsis and is responsible for 50% of all cases of sepsis in the U.S. The risk of developing sepsis is increased among the elderly.

Ventilators and pneumonia

A ventilator is a medical device used to assist a patient with shortness of breath. A ventilator may supplement a patient’s breathing or it may take over the task of breathing for the patient completely. Ventilators may deliver oxygen through tubing inserted into the nose or mouth or through a hole in the front of the neck.

Ventilators are usually intended to be used temporarily for short periods of time although some ventilators may be used long-term. In the case of respiratory failure caused by pneumonia, a patient who requires a ventilator is usually monitored continuously in an ICU. Medical staff in the ICU are able to see how many breaths per minute a patient is breathing and how much oxygen is circulating through their blood at all times. As a result, they are able to respond quickly to any changes in these readings.

Ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is a type of pneumonia that occurs in patients who are on a ventilator. This infection is caused by bacteria entering the patient’s lungs through the ventilator tubing. This infection may be treated with antibiotics, however, because it occurs in patients who are already medically fragile, prevention is important. Some important prevention steps include:

  • Keep the head of the bed raised between 30-45 degrees if possible to allow for deeper, more productive breathing.
  • Clean the inside of the patient’s mouth regularly to prevent any bacteria that may be developing in the mouth from getting into the tubing.
  • Check regularly to see if the patient is able to breathe on their own so they may be taken off the ventilator as soon as possible.
  • Ensure anyone interacting with the patient is properly washing their hands including hospital staff and family members.

It is recommended that you advocate for your family member to ensure these things are happening. Speak with hospital staff about when family member is expected to be taken off the ventilator and ask about the head of their bed being raised. It is important to ask for staff assistance rather than trying to implement any preventive measures yourself, however, as there may be other medical reasons for not raising the head of the hospital bed for example.

Recovery from pneumonia

Even after treatment for pneumonia is complete and your family member’s lungs are clear, they may still need time to recover. Pneumonia often leaves people feeling tired and weak for weeks or even months after the illness. This recovery time may be even longer in seniors or in individuals with other chronic health conditions.

During this time, your family member may not be able to care for themselves the way they did before they had pneumonia. In addition to weakness, pneumonia may cause confusion in the elderly which may linger, especially in individuals who were already in the early stages of dementia or Alzheimer's prior to contracting pneumonia. In severe cases, such as cases that lead to respiratory distress, your family member may still need breathing treatments or need to be hooked up to a portable oxygen tank.

Long-term care options after pneumonia

After pneumonia (especially pneumonia that required hospitalization), your family member may not be able to care for themselves for a while and it may be necessary to consider long-term care options. You will need to consider your family member’s lifestyle, medical needs, and personal support system to determine what type of care is right for them.

Skilled nursing facilities (SNF)

At a skilled nursing facility (SNF), your family member will receive round-the-clock care from a healthcare team. The staff will help your family member recover from pneumonia and help them get healthy enough to return home if possible.

Your family member will have a physician who oversees their care in the SNF. Nurses, nursing assistants, respiratory therapists, physical therapists, occupational therapists, speech therapists, social workers, audiologists, and dietitians will also be a part of your family member’s team as needed.

After pneumonia, your family member may need to see a respiratory therapist daily due to shortness of breath. A respiratory therapist may check their breathing rate, the amount of oxygen in their blood, and the quality of breaths they are taking. If your family member is on a respirator or ventilator, a respiratory therapist will help them wean off of the machine by strengthening their lungs and helping them breath on their own.  Eventually, your family member may be able to use a small, portable oxygen tank, allowing them to leave the bed and move around the facility.

Even if your family member is not able to get out of bed, physical and occupational therapists will see and treat them, helping them move their limbs in bed to prevent pressure ulcers and improve their range of motion. Nursing staff will help your family member sit up and provide any other treatments their physician has ordered.

A speech therapist may see your family member to help with swallowing or language, particularly if they needed a tracheotomy in their neck in the hospital to assist with their breathing. Nursing assistants will help your family member stay clean and help them eat their meals.

A stay in a SNF is covered 100% by Medicare for the first 20 days. On days 21 through 100, Medicare pays a portion of the cost and your family member will need to pay the remaining cost. After 100 days, Medicare will no longer pay for skilled nursing care. If your family member still requires skilled nursing care after 100 days, they will need to consider other ways to pay such as Medicaid, long-term care insurance, or private pay.

The staff at the SNF should keep you informed about your family member’s progress. A social worker will set up care meetings so you can meet with nurses and therapists to talk about the recovery process. If your family member is not able to safely leave the SNF after 100 days, you should know this well in advance.

Assisted living facilities (ALFs)

If your family member does not require any skilled health care after they recover from pneumonia but they are still not able to live at home safely, an assisted living facility (ALF) may be a good choice.

In an ALF, your family member will have more independence than in a SNF, however, they will receive help with personal care and usually medications as well. Before moving into an ALF, the care home staff will want to meet your family member to make sure they are able to meet their needs. They may do a series of assessments to make sure their community is the safest choice for your family member.

Unlike a SNF, an ALF will not have therapists on staff. Personal care assistants will help your family member with daily activities such as getting in and out of bed, getting to meals, getting dressed, and showering.

The types of daily living tasks that staff at an ALF provide assistance with varies. For example, one facility might be able to help your family member eat if they are no longer able to feed themselves while another facility may require that residents are able to do this on their own.

While skilled care services are not provided in ALFs, staff members (usually licensed practical nurses) will assist your family member with taking their medications and with some treatments. As with daily living tasks, the nursing treatments that staff may help with will vary as well. As a result, it is important to be clear about what your family member needs help with when researching facilities to ensure an ALF is the right type of accommodation for them.

Some facilities partner with home health care or hospice teams to bring in outside physical or occupational therapists for residents who may need them. They may also bring psychologists and other specialists into the facility. Insurance and orders from your family member’s primary healthcare provider will determine whether your family member is able to be treated by these professionals if their services are offered at the facility.

In addition, ALFs normally provide housekeeping, laundry, transportation, recreational activities, and meal services. Your family member will be able to personalize their room or suite with pictures, blankets, and even furniture from home.

All personal items brought into the facility will need to be checked by staff to make sure they comply with state-specific safety regulations, however, most items will be allowed. The staff may even be able to help your family member arrange their personal items in a way that follows the facility’s safety rules while still providing your family member with familiarity. This can aid in their recovery and help your family member feel more independent and comfortable at the facility.

Since different ALFs offer different services and types of care, it is important to ask about the monthly cost of care and what services this includes. In addition, be sure to ask what other services are offered and what the cost is for each of these services as well.

Medicare does not cover assisted living. Your family member may be able to use long-term care insurance, Medicaid, or private pay options to cover the cost of assisted living.

Home health care

Many people prefer to recover in their own homes. If your family member is able to safely recover at home, home health care may be the best option. Home health care providers bring a team of skilled healthcare professionals into your family member’s home. For people who do not want to leave their familiar surroundings or lose their sense of independence but need assistance recovering from pneumonia, home health care can help in the transition home from the hospital. Home health care is often a great choice for individuals who live with a spouse/partner or another caregiver since the caregiver remains in the home to provide assistance when home health care staff are not present.

Members of the home health care team will provide your family member with skilled care in the home. A respiratory therapist may visit to check on how their breathing is progressing, administer any breathing treatments, listen to the quality of their breathing with a stethoscope, and make sure they are on the correct level of oxygen or breathing assistance.

The home health agency will make sure your family member has the needed equipment for their oxygen therapy and will help get new equipment if the respiratory therapist and physician feel they require different respiratory equipment.

Nurses and nursing assistants will also visit your family member at home. Nurses may give medications, administer treatments, and check on your family member’s overall condition. They may also teach your family member or a caregiver how to perform some of the needed care themselves once home health care is no longer needed. A home health aide will help with bathing, dressing, and other daily activities. Therapists will visit to help your family member recover from any weakness and to help them mobilize which will help speed their overall recovery.

Home health care does not provide 24-hour care. A home health care agency can work with your family member to arrange a schedule that works best for them but they will not be able to provide round-the-clock care the way a SNF or ALF or would. If your family member lives alone and needs frequent assistance with daily tasks or treatments, home health care is likely not a safe choice, especially if they do not have a spouse/partner or family member who lives with them.

If your family member was hospitalized for pneumonia and requires home health care during their recover, Medicare will pay for 100% of home health care costs. The home health care agency must be Medicare-certified and a physician must certify that your family member needs a skilled level of care. The need for skilled care must be both part-time (less than 8 hours a day) and temporary (expected to last for less than 21 days). Any equipment your family member needs, such as oxygen, will also be covered by Medicare.

If your family member will need the services of a home health care agency for an extended period of time or needs non-skilled home care services such as regular home health aide visits, Medicare will not pay for these services. To pay for these types of services, your family member will need to look into other payment options such as Medicaid, PACE programs, long-term care insurance, or private pay.

Prevention of pneumonia

Since pneumonia can be a life-threatening illness that may take a person a long time to recover from, taking the recommended steps to prevent pneumonia is important.

Pneumonia vaccines

The pneumococcal vaccine is used to vaccinate against all diseases caused by strains of the pneumococcus bacteria including pneumococcal pneumonia, a common type of bacterial pneumonia. Other illnesses caused by pneumococcus bacteria include sinus infections, ear infections, meningitis, and bacterial infections of the bloodstream.

The U.S. Department of Health and Human Services recommends that all adults 65 years and older receive 2 pneumococcal vaccines. Speak with your family member’s healthcare provider about this vaccine to see if it is appropriate for them. Even if your family member has had a pneumococcal vaccination in the past, their healthcare provider may recommend they receive the vaccine again. If your family member has had an allergic reaction to the vaccine in the past, they will not likely be able to receive it again but other options may be available.

There are two vaccines for pneumococcal disease: PPSV23, known as Pneumovax, and the new PCV13. These vaccines protect against different strains of pneumococcal bacteria and should be given at least 1 year apart.

The Centers for Disease Control and Prevention (CDC) recommends that an individual should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 1 year later. If an individual has already received any doses of PPSV23, they should wait to receive the dose of PCV13 at least 1 year after the most recent PPSV23 dose. However, this may vary depending on history of vaccines and illnesses, so it is important to talk to your family member’s current healthcare provider.

While pneumococcal vaccines only protect against pneumonia caused by the pneumococcus bacteria, getting vaccinated is still an important precaution and may prevent many cases of pneumonia.

Flu shots and pneumonia

Since pneumonia may be caused by viruses including the influenza virus, getting a flu shot may help prevent pneumonia as well as the flu. Additionally, the flu may cause a weakened immune system which may make a person more susceptible to respiratory infections including pneumonia.

Unlike pneumococcal vaccines, a flu shot needs to be given every year. Your family member may receive their flu shot during a regular visit to their healthcare provider, at a pharmacy, or at a senior center. If your family member lives in an assisted living community, the flu shot may be provided to residents.

After pneumonia

While recovery from pneumonia may be a slow process, in most cases, your family member will have their breathing and energy level return to normal within weeks of their lungs clearing. Taking steps to ensure your family member is well cared for from the initial diagnosis of pneumonia through the various stages of recovery may help them return to their previous level of functioning as soon as possible.