It’s that time of year. Pneumonia time.
There are two major types of pneumonia — bacterial and viral — and sometimes differentiating between them can be tough. Most pneumonias are caused by viruses and accompany other cold symptoms. Viral pneumonia typically presents pretty early in the course of illness and is hallmarked by lots of cough, decreased appetite, fatigue, and looking sicker than you should with just a cold. Sometimes fever accompanies viral pneumonias but not always. When seen on X-ray, viral pneumonias often look patchy, sort of like clouds on the black background of the lungs and rarely cause fluid to collect around the lung.
Bacterial pneumonias tend to be more severe and serious. They may or may not be accompanied by a cold but if cold symptoms are present, the bacterial pneumonia is usually a secondary infection occurring mid way or later in the illness. What differentiates bacterial pneumonia from viral are very rapid breathing (over 50 breaths per minute), higher fever, and lower oxygen levels than viral pneumonias would cause. On X-ray, bacterial pneumonias look like an area of the lung is a complete white out and there may be fluid around the lunch called an effusion. Kids with bacterial pneumonia are huffing and puffing and even though fever alone can make you breath faster, huff and puff, these kids continue to do so even after some fever reducing medication. Grunting at the end of a breath is another sign that bacterial pneumonia may be present. These kids look sick, really sick.
When we hear what sounds like pneumonia on exam in the office in a child who doesn’t look very ill, has a decent pulse ox indicating they have enough oxygen in the blood, and who isn’t breathing excessively rapidly, we have a decision to make. X-rays aren’t always needed when pneumonia is suspected, since they don’t usually change our management in mild or moderately ill children, but deciding whether or not to start antibiotics is thorny. Viral pneumonias will not respond to antibiotics at all and with the side effects they can cause and the risk of inducing resistant bugs, using them isn’t a good idea. The problem is that sometimes you just can’t know for sure if a pneumonia is bacterial or viral, so there are times when we send a viral swab to the lab and if it comes up negative for the common winter viruses, we will choose to put kids on antibiotics to be on the safe side.
Children who look sick, are breathing fast, have evidence of a bit less oxygen in their blood, and who have fever will likely benefit from antibiotics. If they aren’t sick enough to need hospitalization, using oral antibiotics and seeing them frequently in the office may make sense. The majority of bacterial pneumonias in children are caused by a strep pneumonia which responds well to high dose amoxicillin. If a day or two passes without significant improvement changing to a stronger antibiotic may make sense.
Walking pneumonia is bacterial too but much much milder. It usually has no fever and is hallmarked by prolonged cough (7 days or more) in a child that doesn’t look very sick. You can hear some junky lung sounds on exam and this responds well to azithromycin.
All in all, most children with pneumonia (either bacterial or viral) fare well and don’t need hospitalization. But if your child is very sick or needs oxygen, getting admitted makes sense.