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Pneumonia

Posted Feb 27 2010 12:00am
Hi All.
I have been sick the entire month of February. Two weeks ago I was diagnosed with pneumonia. This has been quite an experience and one I do not wish to repeat ever again. Next week, I am off to a pulmonologist and when I recover, I will take the pneumonia vaccine and start focusing on improving my respiratory function. My chest CT suggests that I may have histoplasmosis (more on that below)as well as aspiration of gastric content during sleep.

This all started off as a respiratory virus that became a secondary bacterial infection. I let it go too long, I just kept waiting for it to pass and instead, ended up with a sinus infection, ear infection and mycoplasma pneumonia. The first time I went to the doctor I ended up at Express Care. Now, I did not have a chest x-ray and was started on a Z-pac. The doctor told me my chest "sounded clear." The Z-Pac helped my sinuses, but did nothing to help my chest. I continued to get worse but kept waiting it all out. It had to end sometime, right? Now, I am lucky I was diagnosed with pneumonia at all and I would not have been, had there not been concern that I was having a pulmonary embolism. (Long story short-I tried to go back to work and ended up being taken to ER in respiratory distress). But even in the Emergency room, two doctors told me I "sounded fine" when listening to my breathing via chest auscultation. My sats were OK too, however, I was hyperventilating, and they decided to go for the chest CT because of my continued shortness of breath. The CT revealed double pneumonia and I was promptly put on some major drugs and breathing treatments. Being diagnosed correctly is major here, people. I could have been missed again. That is scary.

Yesterday I went to the doctor for follow up and after weeks of this, 10 days of antibiotics, I am still running a 99.5 fever (while taking aspirin) and my sats were 89 with a resting heart rate of 108. Fatigue factor is out of this world. Think of all our kids who have fatigue related issues with safety when eating. Wow.

I am going to share a few of my observations about having pneumonia and sinus infection related to eating and trying to help our kids when they become ill and some more information for your reference on pneumonia below.

Breathing-Now after I knew what I had, I did a lot of things to try to clear my chest. I have worked with wonderful PT's over the years and observed a lot of chest PT sessions. I have also had had my own therapy too with myofascial release to my ribcage. I did spend some time briefly on the therapy ball to open my chest, I did deep breaths with a strong, forced exhalation three times every hour on the hour. It was really bad, but broke up a lot of horrible congestion. I walked on the treadmill for about 5 minutes when I could, just to move. It started to hurt to sit back on a chair. My lungs ached and I was wheezing. The worse part was not being able to sleep all month, sitting up in a chair or feeling like I was drowning at night. I also put myself on full reflux precautions trying to protect myself from gastric aspiration. Just the side effects of my multiple medications was enough to totally throw my GI tract out of whack. Like a snowball rolling downhill, each of these issues had the potential to cause new and even more serious problems. Other things that helped me included Ocean Saline Spray and Neti-Pot for sinus wash. Dr Ettema advised me to use the Neti-Pot for two weeks daily and then every other day. This is not pleasant and head position is key to doing this safely without pouring it all down your nasopharynx into your oropharynx. Aspiration risk is high with this product if not done correctly and without a doctor's guidance.

Eating-I felt like I was dying every time I ate a meal. I was weak and seeking food, but it was hard to eat. I felt like I had a gallon Ziploc bag of water on my chest. It was very hard to coordinate chewing/swallowing with breathing. I selected certain foods and totally rejected others. Because of my huge drugs and risk for developing c-dif I was supposed to eat yogurt. There are no words to tell you how aversive I was to yogurt and milk products during this illness. I had to put Grape Nut flakes (which I hate) in the yogurt to make it a texture I could stand. I did not want anything to do with it. I just keep imagining our kids who have to drink Pediasure or milk based supplements....ewww. Actually, I craved chicken noodle soup, chicken and noodle dishes of any kind. I had chicken noodle soup at 9 am one morning. If soup is too thin, instant potato flakes can be added to broth soups to thicken if needed. I wanted bread, crackers and soups. After having soup, I could breathe easier for a while.

Sensory note-I coughed up all this horrible stuff. Just trying to clear it safely was an issue. I started vomiting/gagging very easily. I just want to gag thinking about it now. But it should be noted, my little OT friends, that one day I used hand soap at my Mom's house and it was a product that was thick and creamy. When it hit my hand, I gagged. I was in such sensory overload then and I still am. I was seeking deep input, every part of my body hurt. I would push against the wall with my legs and try to relieve my discomfort. Some types of clothing actually hurt. I was also "dark and foul." Distraction helped, really good movies helped, but anything had potential to quickly become annoying, music, commercials with a sudden increase in volume could really set me over the edge and add to my distress.

Hydration-I avoided water and that was stupid. I KNOW better and literally for one week, I had no water. Just tea, diet soda and coffee. I didn't want it, I coughed when I drank it. I began forcing myself to drink via straw and that really helped. I could have also had Fruitsations pear applesauce, that wouldn't have been bad, it would have been easy to eat and I wouldn't have aspirated it. I could have done shaved ice too or ice based smoothies, flavored or carbonated water...I know this stuff, but I was too sick to care. Really watch those kids that have problems drinking safely. If you have a feeding tube, USE it. Don't push oral intake. It is so hard to safely take liquids when your respiratory function is compromised. Many times I felt I was aspirating and could have been. There are studies that show that typical kids with RSV aspirate during the illness and it resolves after the illness passes. High calorie foods may also help during this time to reduce volume.

Signs and Symptoms of Pneumonia in Children
Often pneumonia begins after an upper respiratory tract infection (an infection of the nose and throat). When this happens, symptoms of pneumonia begin after 2 or 3 days of a cold or sore throat.

Symptoms of pneumonia vary, depending on the age of the child and the cause of the pneumonia. Common symptoms includefever
chills
cough
unusually rapid breathing
breathing with grunting or wheezing sounds
labored breathing that makes a child's rib muscles retract (when muscles under the rib cage or between ribs draw inward with each breath)
vomiting
chest pain
abdominal pain
decreased activity
loss of appetite (in older kids) or poor feeding (in infants)
in extreme cases, bluish or gray color of the lips and fingernails
Sometimes a child's only symptom is rapid breathing. Sometimes when the pneumonia is in the lower part of the lungs near the abdomen, there may be no breathing problems, but there may be fever and abdominal pain or vomiting.


MORE ON HISTOPLASMOSIS AND TYPES OF PNEUMONIA
Histoplasmosis-What does that mean? Histoplasmosis is a fungal infection. It occurs throughout the world. In the United States, it is most common in the southeastern, mid-Atlantic, and central states. The infection enters the body through the lungs. Histoplasma fungus grows as a mold in the soil, and infection results from breathing in airborne particles. Soil contaminated with bird or bat droppings may have a higher concentration of histoplasma. There may be a short period of active infection, or it can become chronic and spread throughout the body. Histoplasmosis may have no symptoms. Most people who do develop symptoms will have a flu-like syndrome and lung (pulmonary) complaints related to pneumonia or other lung involvement. Those with chronic lung disease (such as emphysema and bronchiectasis) are at higher risk of a more severe infection.
About 10% of people with histoplasmosis will develop inflammation (irritation and swelling) in response to the initial infection. This can affect the skin, bones or joints, or the lining of the heart (pericardium). These symptoms are not due to fungal infection of those body parts, but to the inflammation. In a small number of patients, histoplasmosis may become widespread (disseminated), and involve the blood, meninges (outer covering of the brain), adrenal glands, and other organs. Very young or very old people, or those who have a weakened immune system (due to AIDS, cancer, or transplant, for example) are at higher risk for disseminated histoplasmosis. So sometimes, we need to look beyond the respiratory infection or pneumonia. This is just one more reason why multidisciplinary care is so important to treatment and prevention of future problems.

TYPES OF PNEUMONIA
Mycoplasma Pneumonia-the responsible organism, M pneumoniae, is a pleomorphic organism that, unlike bacteria, lacks a cell wall, and unlike viruses does not need a host cell for replication. The prolonged paroxysmal cough seen in this disease is thought to be due to the inhibition of ciliary movement. The organism has a remarkable gliding motility and specialized filamentous tips end that allows it to burrow between cilia within the respiratory epithelium, eventually causing sloughing of the respiratory epithelial cells.

The organism has two properties that seem to correlate well with its pathogenicity in humans. The first is a selective affinity for respiratory epithelial cells, and the second is the ability to produce hydrogen peroxide, which is thought to be responsible for much of the initial cell disruption in the respiratory tract and for damage to erythrocyte membranes.

The pathogenicity of M pneumoniae has been linked to the activation of inflammatory mediators, including cytokines. A recent study reported on a recent emergence of drug-resistant M pneumoniae infection; however, the study concluded that host immune maturity and not the virulence factor of the organism is a major determinant factor of disease severity. M pneumoniae is now recognized as one of the most common causes of community-acquired pneumonia in otherwise healthy patients younger than 40 years, with the highest rate in individuals aged 5-20 years. M pneumoniae causes upper and lower respiratory illness in all age groups, particularly in temperate climates, and in summer, may cause as many as 50% of all pneumonias. Mycoplasmal pneumonia can occur at any time of the year, but large outbreaks tend to occur in the late summer and fall. The incubation period tends to be smoldering and averages 3 weeks, in contrast to that of influenza and other viral pneumonias, which is generally a few days. Epidemics of mycoplasmal pneumonia tend to occur every 4-8 years in the general population and tend to be more frequent within closed populations, such as in military and prison populations. Although M pneumoniae is a common cause of pneumonia, only 5-10% of infected patients actually develop pneumonia.

Streptococcus pneumoniae (pneumococcus) is a bacterial pathogen that affects children and adults worldwide. It is a leading cause of illness in young children and causes illness and death among the elderly and persons who have certain underlying medical conditions. The organism colonizes the upper respiratory tract and can cause the following types of illnesses: a) disseminated invasive infections, including bacteremia and meningitis; b) pneumonia and other lower respiratory tract infections; and c) upper respiratory tract infections, including otitis media and sinusitis. Each year in the United States, pneumococcal disease accounts for an estimated 3,000 cases of meningitis, 50,000 cases of bacteremia, 500,000 cases of pneumonia, and 7 million cases of otitis media (1-4). The focus of this report is the prevention of invasive pneumococcal disease (i.e., bacteremia, meningitis, or infection of other normally sterile sites) through the use of pneumococcal polysaccharide vaccine. This vaccine protects against invasive bacteremic disease, although existing data suggest that it is less effective in protecting against other types of pneumococcal infection.


Severe pneumococcal infections result from dissemination of bacteria to the bloodstream and the central nervous system. Data from community-based studies indicate that overall annual incidence of pneumococcal bacteremia in the United States is an estimated 15-30 cases per 100,000 population; the rate is higher for persons aged greater than or equal to 65 years (50-83 cases per 100,000 population) and for children aged less than or equal to 2 years (160 cases per 100,000 population) (5-9). In adults, 60%-87% of pneumococcal bacteremia is associated with pneumonia (10-12); in young children, the primary sites of infection are frequently not identified.
For more info go to http://www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm.

Viral Pneumonia Causes
Viral pneumonia can be caused by influenza virus, respiratory syncytial viru s (RSV), and the herpes or varicella viruses, including those that cause the common cold (parainfluenza and adenoviruses).

Influenza A and B usually occur in the winter and spring. In addition to the respiratory symptoms, you can get headache, fever, and muscle aches. Your chance of catching the flu falls a lot (but is not totally prevented) if you get a "flu shot" every year.
Respiratory syncytial virus (RSV) is most common in the spring. It usually infects children and can cause outbreaks in daycare centers.
Herpes or varicella pneumonia are rare unless you are infected with chickenpox.
Adenovirus and parainfluenza viral pneumonias are often accompanied by cold symptoms such as runny nose and pinkeye (conjunctivitis).

Aspiration Pneumonia-
Aspiration is the passage of food or liquid through the vocal folds. People who aspirate are at increased risk for pneumonia. People without swallowing abnormalities routinely aspirate microscopic amounts of food and liquid. Gross aspiration, however, is abnormal and may lead to respiratory complications.

Several factors influence the effects of aspiration: quantity, depth, physical properties of the aspirate, and pulmonary clearance mechanisms. Aspiration of larger quantities of material is riskier than aspiration of minute quantities of food or liquid. Aspirating material into the distal airways is more dangerous than aspiration into the vocal folds. Solid food may cause fatal airway obstruction. Acidic material is dangerous, because the lungs are highly sensitive to the caustic effects of acid. Aspirating material laden with infectious organisms or even normal mouth flora can cause bacterial pneumonitis. Pulmonary clearance mechanisms include ciliary action and coughing. Aspiration normally provokes a strong reflex cough. If sensation is impaired, silent aspiration may occur. The severity of aspiration can be described by estimating the percentage of the total bolus aspirated or by estimating the depth of bolus invasion into the airway. The usual site for an aspiration pneumonia is the right lung. Aspirated material will enter the lower lobes when the patient is standing. If the patient is supine then the aspirated material will enter the apical segment of the lower lobes or the posterior segment of the upper lobes. Assessment for dysphagia/swallow dysfunction is recommended when the child has recovered. Hospitalization may be required for management of the illness. Treatment and management measures vary depending on the severity of the pneumonia and type of dysphagia.

With treatment, most types of bacterial pneumonia can be cured within 1 to 2 weeks. Viral pneumonia may last longer. Mycoplasmal pneumonia may take 4 to 6 weeks to resolve completely

Talk to your doctor about all these issues when kids are ill with pneumonia. This is a very serious illness and hard to recover from, but there are many things we can do to help these children (and adults) feel better.
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