Understanding Pneumonia, a Dangerous Coronavirus Complication

Catherine Roberts

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Scientists—and the rest of us—are learning more each day about COVID-19, the illness caused by the novel coronavirus that’s been spreading across the globe

For those who come down with COVID-19, developing pneumonia is a common complication.

“Pneumonia is essentially an infection of the lungs,” says Nikita Desai, M.D., a pulmonary and critical care physician at Cleveland Clinic. Symptoms can include cough, shortness of breath, fever, malaise, chest pain, and the production of sputum, or phlegm.

Pneumonia is sometimes on the milder side—meaning that you can still go about at least some of your daily activities, even though you may feel quite sick. This is sometimes called walking pneumonia, because you can walk around, Desai says. 

In many instances, however, pneumonia is severe, sending people to the hospital, requiring the use of a ventilator, or even leading to death. COVID-19 aside, pneumonia generally sends more than 250,000 people to the hospital and kills about 50,000 each year, according to the Centers for Disease Control and Prevention. 

We don’t yet know what percentage of people with COVID-19 will go on to develop pneumonia, but we know that some have died as a result. We spoke with pulmonary medicine experts to find out what scientists currently understand about COVID-19-related pneumonia. Here, the answers to key questions.

What Causes Pneumonia?

Bacteria, fungal infections, and viruses such as the coronavirus can all lead to pneumonia, although the way it develops can vary. For instance, viruses can cause pneumonia directly. But in some cases, if a viral respiratory infection is severe enough, it can damage the lungs and leave them vulnerable to a secondary infection: bacterial pneumonia. This is common with flu, though scientists aren’t exactly sure how often it occurs. 

How Might I Know If I Have Pneumonia?

Doctors usually diagnose pneumonia by evaluating your symptoms—and by taking an X-ray of your chest. An X-ray is critical in diagnosing pneumonia, according to Nicholas Hill, M.D., chief of the division of pulmonary critical care and sleep medicine at Tufts Medical Center in Boston and a past president of the American Thoracic Society. “We often see what we call infiltrates, abnormal shadows that indicate the presence of a pneumonia,” he says.

A doctor may also listen to your breathing for the crackling sounds of fluid in your lungs, which can occur because of inflammation from infection, he says.

How Is Pneumonia Usually Treated?

If your doctor diagnoses you with pneumonia, you’ll probably undergo additional tests to help determine whether your illness is caused by bacteria or viruses, because the treatment depends on the type. But this can be tricky, in part because you may have a viral infection and a secondary bacterial pneumonia infection at the same time. 

Sometimes, viral infections can be identified. For instance, your doctor can give you a flu test, which will return a quick result. If flu is the cause, you’ll probably receive an antiviral medication such as oseltamivir (Tamiflu). 

But test results for bacterial pneumonia, which is treated with antibiotics, may take a day or two, and even with testing, doctors often can’t pinpoint the cause. In these cases, it may be unwise to wait before starting antibiotics, notes Hill, for fear of the condition worsening. So antibiotics are often prescribed before tests results arrive—frequently amoxicillin is given first. Once test results return, the type of antibiotic prescribed may be adjusted to better target the underlying bacteria. (Scientists are working on developing better tests to pinpoint bacterial causes earlier, to reduce the unnecessary use of these drugs.)

Some people become ill enough with pneumonia to require hospitalization. If you have pneumonia, doctors may decide whether you need to stay in a hospital by looking at the level of oxygen in your blood, whether you have any cognitive or functional impairments, whether you show signs of sepsis (a life-threatening complication of an infection), and other factors.

Is Pneumonia Related to COVID-19 Being Diagnosed and Treated Differently?

Diagnosing pneumonia right now may be more challenging than usual, because of the logistics of taking X-rays in people suspected of having COVID-19, according to Michael Niederman, M.D., clinical director and associate chief of pulmonary and critical care at Weill Cornell Medicine. That’s because imaging equipment used for someone who may have COVID-19 requires extensive disinfecting afterward, and various people and areas of the hospital or health center may be exposed before, during, and afterward. For COVID-19, he says, “The very starting point of doing an X-ray to recognize pneumonia is not as simple as it was.”

Otherwise, a case of COVID-19 pneumonia is generally diagnosed in the same way as other types. Sometimes, chest X-rays can hint at whether a pneumonia is viral or bacterial, but even in cases of a probable viral cause, the image can’t tell doctors which virus is the culprit, Desai says. Testing for flu—and, if that test is negative, then testing for COVID-19—can help pinpoint the cause.

In terms of treatment, even though COVID-19 is a virus, people who develop severe pneumonia are likely to be given antibiotics, just in case of a secondary bacterial infection, according to the experts we spoke with. 

So far it’s unclear how often people with COVID-19 develop secondary bacterial pneumonia, says Charles Dela Cruz, M.D., Ph.D., director of the Center of Pulmonary Infection Research and Treatment at Yale University. But during the H1N1 influenza pandemic in 2009, secondary bacterial infections were common. 

Beyond that, however, another major difference with COVID-19 is that there are no treatments proved to effectively fight the virus. Those hospitalized for COVID-19 will receive supportive care, such as oxygen. Some people have also received antiviral drugs, but none have yet been shown to be effective against the virus in clinical trials.

Are Some People More Likely to Have Serious Effects From Pneumonia?

The people who are most at risk from a serious pneumonia are older adults and people with underlying health conditions, including diabetes, heart disease, lung disease, and anyone with a suppressed immune system. In the CDC’s most recent data, people ages 85 and older faced the greatest risk of dying from COVID-19 (though the data didn’t break down the specific causes of death).

It’s important to note that pneumonia isn’t the only potentially severe complication of COVID-19. Also possible are sepsis, organ damage, and a condition called acute respiratory distress syndrome (ARDS), which occurs when fluid collects in the lungs. People with ARDS often need the assistance of ventilators in order to breathe. All these complications are more likely in people in high-risk categories.

What Should I Do If I Suspect COVID-19 or Pneumonia?

The main symptoms of COVID-19 are fever, cough, and shortness of breath. According to the CDC, you should call a healthcare provider if you develop these symptoms to find out whether you need to seek medical attention—many people may not need to be treated in a clinic or a hospital for COVID-19 or a mild case of pneumonia.

If you don’t need to be hospitalized, stay home, get lots of rest, and stay hydrated. Try to steer clear of any other people in your home, and keep up with good hygiene practices like handwashing and covering your cough, in order to avoid infecting anyone else.

Generally speaking, having trouble breathing and consistent chest pain are signs of a possible emergency from pneumonia, flu, or COVID-19 and should prompt you to immediately seek care. Normally, that would mean visiting an emergency department. Now that COVID-19 is circulating widely, the CDC recommends calling 911 and telling the operator you might have COVID-19 so that responders can prepare appropriately.

Should I Get Vaccinated Now Against Flu and Pneumococcal Bacteria?

Along with the flu shot, vaccines are available against some of the common bacterial causes of pneumonia. Pneumococcal vaccines are recommended for adults ages 65 and older, and people with certain underlying health conditions. 

We asked experts whether it’s still a good idea to get a flu shot if you haven’t had one this year, given that flu season has begun to wane. 

Dela Cruz says he’s hesitant to recommend a flu vaccine right now, especially for people who are in high-risk categories, because of the possibility of exposure to coronavirus during a visit to a healthcare office or clinic. While it’s important to reduce your likelihood of flu right now, if you opt for a vaccine, Hill recommends getting it at a pharmacy rather than a doctor’s office. “You'd rather go to a place where people who might have COVID aren’t hanging around,” he says.

As for the pneumococcal vaccine, Niederman recommends consulting your doctor beforehand to make sure you’ll be getting the one that’s most appropriate for you and at the right time. (All adults should get the vaccine known as PPSV23, or Pneumovax, at age 65; some should also get PVC13, or Prevnar 13.) And if you get the vaccine, do so at a pharmacy.



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