Beware of the False Pneumonia

Beware of the False Pneumonia

Pneumonia.  

We are seeing a continuing and rather dramatic rise in how often families are told their children have pneumonia, especially in ER's and Urgent Care Centers.

But it turns out that the pneumonia that these centers are talking about is quite different than what most people think pneumonia is.   

For most of history, and in most everyone's mind, pneumonia was a very dangerous illness, caused by potentially very deadly bacteria.  Pneumonia was an illness where bacteria created a lot of pus in the lungs, causing a very rapid decline and significant danger.  

Technically, this is a form of pneumonia called bacterial pneumonia, and when you get this disease, you get very sick, very rapidly, and in its more severe forms, you can get quite a bit sicker every hour.  Some forms of this disease can also be quite dramatic in their recovery, with some people getting so much better on antibiotic that they feel good within hours of starting antibiotic.

This is not the disease that is being diagnosed as pneumonia thousands of times a day in ER's and Urgent Care Centers across the country.  The pneumonia being diagnosed so frequently now is a type of pneumonia, and so technically is not a "false pneumonia," but it often is an illness that really has no relationship whatsoever to bacterial pneumonia.

The illness being called pneumonia, most frequently in children, is really a type of cold, that in the vast majority of circumstances poses no risk to the safety of a child, and will not benefit at all from use of antibiotic.

What is this form pneumonia that is so unrelated to what we have all long thought pneumonia was about?  It is an illness called viral pneumonia.

Viral pneumonia can be very severe, but in the vast majority of cases seen in kids, it really is, as noted above, much much more like a cold than like bacterial pneumonia.   

Bacterial pneumonia in its full form tends to be a very rapidly progressing process where you get seriously ill very rapidly and can get worse every hour.  Left untreated, bacterial pneumonia can be a very dangerous illness.  At its heart, bacterial pneumonia destroys lung tissue and creates a ton of pus in the lungs.

Viral pneumonia, typically, makes you breathe faster and cough a lot, but does not much more than that.  It can also cause fever and feeling lousy, but it tends to make you ill to a certain degree- a certain amount of fever, misery, cough- and then you stay that sick for a few days or weeks, then recover.  There is typically, in the most frequent  mild forms, no progression.  Rather, you just sit there at that level of illness for a long stretch of time.  Viral pneumonias, at their heart, cause swelling and mucus production, some pus, but not nearly as much as with the unrelated illness, bacterial pneumonia.  

And, there is essentially no drug that cures viral pneumonia.  Antibiotics are useless for this disease, since antibiotics only kill bacteria, and there are no bacteria to kill in the illness, viral pneumonia.

Now here is the core source of confusion between these two very different, unrelated diseases, you can't tell the difference between them by looking at a chest X-ray.  The X-ray, CT Scan, and MRI cannot tell the difference between pus and mucus.  Bacterial pneumonia makes pus, viral pneumonia mucus, no imaging scan or X-ray can tell the difference between the two.

This confusion led the nation's two top professional societies on the subject of pneumonia* to make a formal recommendation that a chest X-ray NOT BE DONE ROUTINELY when a child is seen in the ER with a question of pneumonia.  Further, these societies noted that the vast majority of pneumonia in childhood is viral, not bacterial, pneumonia; and, therefore antibiotics should NOT BE PRESCRIBED ROUTINELY, if it clear the illness is more viral in nature.

BOTTOM LINE:

1. The two diseases, bacterial pneumonia and viral pneumonia, are not similar, related, or have anything to do with each other, beyond both affecting the lung.
2.  Bacterial pneumonia can be very dangerous, making you sicker by the hour, and involves production of lots of pus in the lung.
3. Viral pneumonia, in its typical form (note that it too can be very severe, but 99% of the time is not) causes much misery from fever and cough, but tends to hover at a certain level of intensity, not changing dramatically over time, but lingering.
4. In children who are not dangerously ill, that is who do not require oxygen, can breathe fairly easily, the vast majority do not have bacterial pneumonia, they have the other illness, viral pneumonia.
5. Chest X-rays and antibiotics are not useful for mild, viral, pneumonias.  In fact, in their milder forms, the viral pneumonias are more accurately described as bad colds in the lung and not "true" pneumonias.  At least they bear no resemblance or connection to what most of us think of as a real pneumonia- which is the bacterial form.
6. Here is the key point:  more than anything else, the difference is in how sick your child is.  That, far more than a Chest X-ray, will determine if the process is dangerous and bacterial or very safe and viral.

Dr. Arthur Lavin

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