A False Epidemic of Pneumonia

Image via WikipediaNot All Pneumonia is the Same:
The Sudden Rise in Numbers of cases of pneumonia,
and the role of Virus

This year we have seen and heard of quite an explosion in the number of children and adolescents being told they have pneumonia.  

Although we cannot comment on any one person's particular diagnosis of pneumonia, an overall view of the major jump in numbers of people being told they have pneumonia does demand some comment.

First, What is Pneumonia?

Pneumonia sounds like a very precise word.  It sounds like the sort of diagnosis that means something very specific.  But it turns out to mean many, many things, and as a result is a very, very fuzzy, vague, and confusing term.

At its root, pneumonia comes from the Greek word pneuma which means breath, and so pneumonia literally means a condition that affects breathing.

Today, pneumonia has come to mean a condition in which the lung is swollen and making enough extra fluid, be it mucus or pus, to make breathing abnormal, or to put it more briefly, a condition in which the lung is inflamed.

Asthma, in contrast, is a condition in which the tubes of the lung are inflamed reversibly.

Now, here is where it can get real confusing, real quickly.  For, if pneumonia is a condition of lung inflammation interfering with breathing, then pneumonia can be caused by dozens of things that make the lungs inflamed.  These causes tend to part of one or another of two main categories of cause:  infection and toxic irritation.

Toxic irritations include inhaling smoke in a fire and getting stuff from your mouth inhaled into your lungs, a process known as aspiration.  Both smoke inhalation and aspiration can cause serious inflammation of the lungs and lead to that type of pneumonia.

When it comes to infections, the main causes in the US are viruses and bacteria.  There is a world of difference between viral and bacterial pneumonia, and it here where the great jump in children being told they have pneumonia is occurring and causing some serious confusion.

Bacterial pneumonia

Of all the various pneumonias, bacterial pneumonia is what most people think of when they say, "So-and-so has pneumonia."  In bacterial pneumonia, especially from bacteria that can act fast, like germs such as the pneumococcus or Hib, you can get dangerously ill.  The bacteria often form little balls of pus that rapidly expand.  If untreated, you can spike very high fevers, sometimes over 105, suddenly have great struggles breathing, and get very sick very rapidly.  Before the days of antibiotics, this was often a deadly illness.  Classic findings on a chest X-ray would be a ball or other shaped collection of pus.

Now, if you are otherwise well, a course of antibiotics normally cures you very rapidly, so the era of most of these pneumonias being dangerous is past.

Bacterial pneumonia, however, still presents a real danger to people whose immune systems or lungs or really any part of the body are weakened by disease.  Despite the progress antibiotics have offered, this pneumonia deserves respect.

In healthy American children, the vast majority of pneumonias are NOT bacterial.

Viral pneumonia

Although bacterial pneumonia is what most people think of when the radiologist or doctor says, "Your child has pneumonia,"  it is viral pneumonia that the child most likely actually has.

Viral pneumonia is, in many ways, a cold that has caused more than expected inflammation in the lung.  There are very, very serious viral pneumonias, but these are unusual and rather rare events compared to the millions and millions of cases of viral infection of the lung that happen in every community in the world, every year.

To understand viral pneumonia, one has to think about viral infections, in particular colds.  When you get a cold, the virus is always doing the same thing to the lining of your tissues- destroying it.  So when a virus infects your nose, it literally burns off the lining of your nose, thus causing all that misery, irritation, mucus, swelling!  This is what happens wherever a virus infects- in the eye it causes redness and wateriness, in the ear an earache, in the throat a sore throat, and in the lung, cough.  

Of all the problems one has with a cold, often cough is the worst.  It hurts to cough, it feels just miserable, and it can go on for many days, sometimes even weeks.  A child coughing heavily for days or weeks on end, up all night, is very hard to tolerate.

In general, however, if your child is breathing very comfortably when not coughing and has no fever and is otherwise acting well, their cough typically does not indicate a serious problem.

Even so, most families will feel like they have reached their limit after some number of days of non-stop cough.  This often happen when cough is at its worst, at night, and the need for medical attention at that time usually leads to a trip to the urgent care or ER.   Most urgent care or ER facilities will order a chest X-ray if someone shows up with a cough they are worried about.

Here is where it gets interesting.  Remember that with any cold, the tissue affected has its lining destroyed, and this causes alot of swelling and mucus production, just like a burn.  Well when a cold hits the lungs, it is like the lungs have been burned.  If you took a look at the lungs, their tubes would be all swollen and red and many plugged with mucus.  If you took a chest X-ray of such lungs, you would suddenly be able to see the tubes of the lungs more prominently, they would appear like white streaks.  If some tubes got plugged the segment of lung they supply would compress as its air was absorbed and would give the appearance of white wedges on the chest X-ray.

So, if you got a chest X-ray on anyone with a cold,  you would likely find some things not seen in people without colds.

In today's cautious medical world, radiologists are very careful about saying that a chest X-ray with some differences is surely not an early pneumonia, so they say, the findings could represent an emerging pneumonia.

Next thing you know, a child with an uncomplicated cold is being told they have pneumonia.  For the radiology report that states the findings could indicate a pneumonia are translated by the urgent care and ER doc into the statement- "Your child has pneumonia."

The Implications

The scenarios above are played out in every city in America every day and night, and as a result, children with colds or other ultimately harmless viral infections are getting alot more chest X-rays, and alot more diagnoses of pneumonia.  This year, we at Advanced Pediatrics have noticed these trends expanding dramatically.  Most families report that many of their children's friends have been diagnosed with pneumonia, but the children do not seem all that ill- running around playing, breathing well, etc.

What to Do

Unfortunately, if a chest X-ray is taken and a radiologist raises the question of pneumonia, one should take a course of antibiotics, just in case a bacterial pneumonia is brewing, even if the course and the child's appearance and exam all suggest the process is viral.

But keep in mind that when your child is told they have pneumonia, chances are very high that what they have is a viral pneumonia, a not so serious illness that is radically different from what most people think of as pneumonia.

BOTTOM LINE

A movement towards obtaining chest X-rays for children who are coughing has led to a big jump in the number of people being told their child has pneumonia.  In the vast majority of these situations, the findings on the chest X-ray are minimal and very consistent with mild viral illness, and in fact, most of the time the children have a viral not bacterial pneumonia.
Bacterial pneumonias can be dangerous and make one very, very ill.
Viral pneumonias, although rarely severe, are in the vast majority of instances pose no danger, and are really simply extensions of the common cold to the lung.
Keep in mind that the diagnosis is pneumonia is far less important than knowing how ill your child is.  If he or she is acting fairly well and simply has a lingering cough, the diagnosis of pneumonia does not suddenly make them more ill or in greater danger.

We at Advanced Pediatrics would be happy to help you sort out these possibilities anytime your child is told they have a pneumonia.


Dr. Arthur Lavin

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