Let’s Talk About Pneumonia
We’ve got the doctor-approved scoop on causes, symptoms, treatments, and a ton of other facts and tips that can make navigating this common lung illness easier.
Maybe you had what you thought was a cold, and it’s not getting better. Or maybe you were doing fine and suddenly got walloped with a high fever, chills, cough, and stabbing pain when you breathe in. What’s going on? You might have pneumonia, a common lung infection that can strike anyone, though young children and older adults are at highest risk. The symptoms can range from mild to life-threatening, but the very good news is that pneumonia is highly treatable, and most people get better within a few weeks. Here’s what you need to know about this condition.
Our Pro Panel
We went to some of the nation’s top experts in infectious diseases and lung disorders to bring you the most scientific, up-to-date information available.
Michael Gutwein, M.D.
Chief Emeritus, Infectious Disease Division
Missouri Baptist Medical Center
St. Louis, MO
Jeffrey Pernica, M.D.
Head, Division of Infectious Diseases and Associate Professor, Department of Pediatrics
Rachel Scheraga, M.D.
Assistant Professor of Medicine and Associate Staff Physician, Pulmonology and Critical Care Medicine
It can be quite dangerous. In an average pre-COVID year, pneumonia affected millions of people in the U.S., sent about 1.3 million to the emergency room, and killed more than 50,000, according to the National Center for Health Statistics. But COVID has driven those numbers much higher, at least for the time being. Pneumonia is even deadlier in less-developed countries. Globally, it’s the leading cause of death in children under age 5, killing some 800,000 children in 2017 alone (the last year for which full stats are available), according to the World Health Organization. The bulk of those deaths were in South Asia and sub-Saharan Africa.
It depends on what type you have and how quickly it’s diagnosed and treated. Most cases of viral pneumonia are relatively mild and clear up within a week or two. In fact, if the infection develops slowly, you may not even be aware that you have it. Bacterial pneumonia is often more serious, especially if it’s left untreated, which can lead to scarring of lung tissue or allow the infection to spread to other vital organs. Once you’re treated, recovery from bacterial pneumonia may take anywhere from 10 days to several weeks.
The CDC recommends the pneumococcal vaccine for all adults ages 65 and over and all kids under 2, as well as children and younger adults with certain medical conditions. There are two types of pneumococcal vaccine: Prevnar 13 (or PCV13) and Pneumovax 23 (PPSV23). Talk with your doctor about which you should have (or if you should get both). The vaccine protects you against the most common type of bacterial pneumonia—not viral pneumonia or other types of pneumonia, like fungal pneumonia.
It’s a dangerous form of pneumonia that can strike people who’ve been in the hospital for some other condition. It happens most often in individuals who are in the intensive care unit (ICU). Though it’s less common than community-acquired pneumonia (pneumonia that develops in non-health-care settings), hospital-acquired pneumonia is the deadliest of any hospital-acquired infection, with mortality rates of up to 33%.
What Is Pneumonia?
Pneumonia is actually an umbrella term for a range of infections that attack your lungs’ air sacs (alveoli) and surrounding tissue. It can cause breathing trouble and flu-like symptoms, and can be a serious health risk for some people if left untreated.
To understand how pneumonia works, it helps to know a bit of lung anatomy: Each of your lungs has a main tube, called a primary bronchus (plural bronchi; also called airways), that carries air into it from your trachea, or windpipe. Each of the bronchi branches off into progressively smaller bronchi, which in turn branch off into thousands of even smaller airways called bronchioles, ending in millions of tiny air sacs called alveoli. The alveoli are covered with tiny blood vessels (capillaries) that carry oxygen to the cells of your body and return carbon dioxide to your lungs to be exhaled.
When you have pneumonia, the alveoli become inflamed and fill up with fluid or pus. This leads to impaired breathing, fever, and other symptoms, like cough (though not everyone with pneumonia gets a cough—it’s tricky that way). The infection may affect a single section, or lobe, of your lung, in which case it’s called lobar pneumonia; or it may happen in several lobes, called multilobar pneumonia. If the inflammation also involves your bronchi, it’s called bronchopneumonia. Pneumonia might affect one lung (unilateral pneumonia), or it might strike both lungs (bilateral pneumonia).
Types of Pneumonia
There are two main types of pneumonia: viral (caused by a virus) and bacterial (caused by, you guessed it, bacteria). It’s possible to have both types at the same time or one right after the other. For example, you could have pneumonia due to the flu, which is caused by a virus (influenza), and then develop bacterial pneumonia. Some experts call this “co-infection.” A third and much rarer kind of pneumonia, called fungal pneumonia, is caused by breathing in spores from certain fungi (mold).
Anyone can develop pneumonia, but in order to get it two things have to happen: One, you need to be exposed to a microorganism, a.k.a. germ (typically a virus or bacteria; much more on this below); and two, that germ has to be able to get past your body’s usual defenses and into your lower respiratory tract—that is, your lungs. For this reason, pneumonia is more common in certain people than others, namely adults over 65 (whose immune systems are weakened by age), infants and young children (whose immune systems are not yet fully developed), and people with weakened immunity due to a medical condition or medication.
Before the coronavirus (COVID-19) pandemic, several million people in the U.S. got pneumonia in an average year, with about 1.3 million sick enough to go the emergency room and more than 50,000 dying from it, according to the CDC. It was the eighth leading cause of death among U.S. adults in 2017. But COVID-19 has exploded those numbers: Between January 2020 and April 2021, the government estimates that more than 260,000 people in the U.S. died from pneumonia related to COVID-19 alone.
What Are the Symptoms of Pneumonia?
Symptoms of pneumonia can range from super mild to severe, depending on lots of factors—your age, your overall health, whether your pneumonia is bacterial or viral, how long you have it before you get treated, and whether you’re a smoker, for example. It’s possible to have such a mild infection that you don’t even know you have it. (This is sometimes referred to as “walking pneumonia.”)
Interestingly, older adults and people with weakened immune systems often have fewer and milder symptoms of pneumonia than younger adults, even though the illness is more dangerous for them. Older adults often have no fever, for example, and they may not have noticeable respiratory symptoms. Instead, a sudden change in mental status, like confusion or loss of awareness, can be a warning sign of pneumonia in this age group. It’s not entirely clear why different age groups manifest pneumonia differently.
Not only do pneumonia symptoms vary widely in severity, but they can also overlap those of other respiratory illnesses, like colds, the flu, and now, COVID (all of which can also lead to pneumonia!). Consider all of that and it’s no wonder that pneumonia is one of the hardest infections to diagnose. That being said, here are the main symptoms you should look out for. Where a symptom applies mainly to one type of pneumonia or manifests differently between types, we’ve noted that.
Chest pain that’s sharp or stabbing. It might get worse when you breathe in or cough.
Chills, possibly bad enough that they make you shake
Cough. In viral pneumonia, the cough might be dry, especially early in the infection. With bacterial pneumonia the cough is often what experts call “productive,” meaning you cough up phlegm. It may be green or yellowish-tan in color or even bloody. As viral pneumonia worsens, it can progress to a productive cough. Even after you recover, the cough from pneumonia can linger for weeks or longer.
Fever (over 100°F and sometimes as high as 105°F; high fever that comes on suddenly is more common in bacterial than viral pneumonia. As a general rule, you should call your doc if you have over 102°F or, if you’re immunocompromised, 100.4°F).
Mental confusion (more common in people over 65)
Muscle pain or headache (more common in viral pneumonia)
Nausea and vomiting (more common in young children)
Rapid pulse—think a substantial increase over your usual resting heart rate—and/or rapid breathing (more common in children and younger adults)
Shortness of breath
Sore throat (more common in viral pneumonia)
Weakness and fatigue
Also worth noting: Viral pneumonia tends to come on slowly at first, with symptoms developing over several days. Bacterial pneumonia, in contrast, usually comes on fast and strong.
When Pneumonia Is an Emergency
In severe cases, pneumonia can cause you to have extreme difficulty breathing or develop a blue tinge to your fingernails, lips, or other skin areas. This is an indication that the level of oxygen in your blood is dangerously low. If you (or your child, or someone you are with) experience these symptoms, don’t wait to talk to your doctor: Call 911 immediately. In addition, young children whose symptoms are preventing them from drinking enough fluids (evidenced by a dry mouth or not wetting their diapers regularly) should be taken to the ER because they may need intravenous fluids.
Is It Pneumonia or COVID?
Here’s something you may be wondering at this point: How do you know if you have pneumonia or COVID? Or both? Or neither, and you actually have, say, the flu? The answer is, it’s really hard to tell—which is why if you’re having the symptoms discussed in this section, it’s important to see your doctor so you can get the right diagnosis.
As long as COVID is active, that almost definitely will entail having a COVID test, since the virus can cause symptoms that overlap those of pneumonia, like fever and coughing, as well as actually lead to pneumonia (in which case it’s called SARS-CoV-2 pneumonia or COVID-19 pneumonia; SARS-CoV-2 is the name of the new coronavirus that causes COVID).
Plus, having COVID makes your lungs vulnerable to infection by any number of bacteria that normally wouldn’t affect you. (This is true of all viruses, which is why bacterial pneumonia often follows a bout of the flu or a bad cold.) In other words, having COVID is a big risk factor for pneumonia…and since we know that COVID is highly contagious and can affect many organ systems other than the lungs, it’s important to know if you’re infected with it (whether or not you currently have pneumonia) so you can be monitored and isolate if needed. Similarly, if you experience pneumonia symptoms during a month when the flu (influenza) virus is circulating, your doctor will probably recommend a flu test.
What Causes Pneumonia?
Like other infections, pneumonia is caused by microorganisms, or teeny tiny germs. Three types of microorganisms can cause pneumonia: viruses, bacteria, and fungi. The most common by far are viruses and bacteria. Some examples of bacteria that cause pneumonia are Streptococcus pneumonia, Mycoplasma pneumoniae, and Staphylococcus aureus (a.k.a. “staph”). Viruses that cause pneumonia include influenza (yep, the same virus that causes flu), respiratory syncytial virus (RSV; this mainly affects babies and young kids), and coronaviruses, including the SARS-CoV-2 (COVID) virus. You can breathe in these germs from the air—say, if a person with pneumonia coughs near you—or by touching a surface or object that an infected person touched or coughed on. Or you could have an existing upper respiratory infection, like the flu or a cold (both caused by viruses), and the germs spread into your lungs, causing pneumonia.
In other cases, bacteria that normally live in your nose and throat without causing trouble can take advantage of a weakened immune system (from a recent illness, a chronic illness, or an immune-suppressing medication, say) to migrate downward into your lungs. Experts call this an “opportunistic infection.”
Sometimes, a person with pneumonia has both a viral and a bacterial infection at the same time. For example, in a large study a few years ago by the Centers for Disease Control and Prevention (CDC), called the Epidemiology of Pneumonia in Communities (EPIC) study, 7% of children hospitalized with pneumonia had both a virus and a bacterium detected in samples of their sputum (phlegm) or blood, and the actual rate of such “co-infection” may have been higher, since some of the samples didn’t return conclusive results.
Much less commonly, pneumonia can be caused by a fungus (a.k.a. mold). This kind of pneumonia mainly strikes people who are immunocompromised or who live in regions of the U.S. where certain fungi grow in the soil. A fungus called Pneumocystis jiroveci, for example, sometimes infects the lungs of people with untreated HIV. In the Southwestern U.S., a fungus called Coccidioides can cause a kind of pneumonia known as “valley fever.” (About 20,000 people in the U.S. get valley fever annually, according to the CDC.) Unlike bacterial and viral pneumonia, fungal pneumonia can’t be spread from person to person. You get it by inhaling fungal spores that become airborne (from the wind, for example).
You can also develop pneumonia if you accidentally aspirate (inhale) food particles, saliva, or refluxed stomach acid into your airways (bronchi) and they spread into your lungs. The particles may have bacteria, viruses, or other microorganisms in them that then infect the lungs. This is called aspiration pneumonia.
With any type of pneumonia, the important question is: How likely are you to get it? And that depends in part on whether you have one or more of certain risk factors. Let’s get to that now.
Pneumonia Risk Factors
A number of health-related factors can increase your chances of getting pneumonia. Some of them you can control; others you can’t. They include:
Being older than 65 or younger than two raises the likelihood of getting pneumonia. That’s because these age groups have weaker immune systems, making them more vulnerable to infection.
Chronic Medical Conditions
In particular, having a chronic lung condition such as asthma, chronic obstructive pulmonary disease (COPD), or cystic fibrosis increases your susceptibility to other lung problems, including pneumonia. You’re also at heightened risk if you have sickle-cell anemia, heart disease, poorly controlled type 2 diabetes, chronic kidney disease, and some types of cancer.
Difficulty Swallowing or Coughing
Trouble swallowing (dysphagia) or a reduced ability to cough increase the risk that you’ll accidentally inhale food or liquid particles into the airway from the throat, which can cause aspiration pneumonia. These problems can stem from a stroke, Parkinson’s disease, a brain injury, or other neurological conditions. You can also experience dysphagia as a side effect of certain medications, including anticholinergics, antipsychotics, benzodiazepines, diuretics, and levodopa.
Heavy Alcohol Use
Drinking alcohol heavily over time weakens your immune system, making it harder for your body to fight off infections.
The risk is highest if you’re in the intensive care unit (ICU), especially if you are on a mechanical ventilator or sedated. Both make it difficult to cough, which increases the chance of getting pneumonia (see section above). And ventilators trap a variety of nasty germs that can infect the lungs.
Living in a Long-Term Care Facility
Germs spread quickly between residents in nursing homes and other long-term care facilities, including drug-resistant bugs like methicillin-resistant Staphylococcus aureus (MRSA), which can cause especially severe and hard-to-treat pneumonia. A recent research review from the University of Michigan notes that residents of long-term care facilities are also more likely to aspirate foods or fluids than elderly people living at home (because of feeding tubes, swallowing difficulties, medications, or other reasons), which can cause aspiration pneumonia.
Recent Major Surgery or Injury
Recovering from a big surgical procedure or traumatic injury often involves lying on your back for an extended period, which can allow fluid or mucus to pool in your lungs, giving bacteria a place to grow. A recent surgery or injury can also make it difficult to cough (see above).
A Recent Viral Respiratory Illness
A recent bout of the flu, common cold, or COVID-19 makes you vulnerable to pneumonia in a few ways. One, the microorganism that caused the original infection (such as the influenza virus, SARS-CoV-2, or a virus that causes colds) may spread to your lungs. Two, having any virus increases your chance of developing a “secondary” bacterial infection. This happens both because your immune system is already embattled from fighting the virus, making it less able to defend against bacteria, and because viruses can cause acute damage to the airways (bronchi) that leaves them open to a bacterial attack.
Smoking causes damage to your lungs that makes them susceptible to infiltration by bacteria and viruses. In one very large meta-analysis, published in the journal PLoS One, smoking more than doubled the risk of getting pneumonia, compared to not smoking. Research also shows that smokers are more likely than non-smokers to die from pneumonia.
People in this group include those living with HIV/AIDS, undergoing chemotherapy, or taking immunosuppressive medication—for example, to treat an autoimmune condition (RA, MS, and IBD communities, we’re talking to you) or because of an organ transplant. If you have compromised immunity, you have a higher risk of infections in general, including pneumonia.
How Is Pneumonia Diagnosed?
You should seek a doctor’s opinion if you are having noticeable symptoms that you think might be pneumonia. Even if it starts off mild, pneumonia can quickly become dangerous in older adults, young children, and people who have an underlying medical condition or are immunocompromised—so if you’re in one of those groups in particular, waiting too long can be risky. Another reason to see the doctor promptly: If untreated, bacterial pneumonia can lead to scarring of the lung tissue or spread to other vital organs.
Here’s what to expect when you see the doctor.
Medical History and Exam
You’ll be asked to describe your symptoms, including when they started and how quickly they came on. The doctor will also do a physical exam, including listening to your lungs with a stethoscope while you breathe in and out. The lungs of people with pneumonia sometimes make a crackling or bubbling sound (only detectable with a stethoscope), an indicator that there’s fluid present. You’ll probably also have your pulse checked to see if it’s unusually fast.
If the doctor suspects pneumonia based on your history and exam, he or she will likely order a chest X-ray next to look for evidence of the infection. Infected lungs may have cloudy sections on the X-ray where the alveoli are filled up with fluid rather than air, or there might be other physical signs of inflammation. The X-ray can also help the doctor see if your pneumonia is in one lung or both, and how much of each lung it’s affecting. Sometimes, a chest X-ray isn’t conclusive. If the doctor wants to see more than what the X-ray shows, you might get another imaging test like a CT scan. This is more likely if your symptoms are pretty serious.
Depending on how sure the doctor is that a) you have pneumonia and b) what’s causing it, he or she may do one or more tests on your blood, like a complete blood count to look for signs that your body is fighting an infection or a blood culture to look for the offending pathogen. (A blood culture is more likely if your symptoms are severe enough that you’re hospitalized.) Knowing the identity of the microorganism infecting you can be useful to the doctor, since different antibiotics align with different bacteria.
Doctors sometimes use additional tests that can help determine whether you have pneumonia and/or what might be causing it. Here are a few examples:
A pulse oximeter test. This measures how much oxygen is in your blood, usually through a small sensor that’s placed on your fingertip.
A COVID and/or flu test. These are done by swabbing your nostrils or your nasopharyngeal passages—the area way up there inside your nose where it meets the back of your throat. (If you’ve had a COVID test, you know a nasopharyngeal swab can be an uncomfortable experience.)
A sputum sample. If you are coughing up phlegm (sputum), you might be asked to produce some and spit it into a sample container in the doctor’s office; it’s then cultured (put into a petri dish) to see what grows. As with a blood culture, the purpose of sputum testing is to help the doctor identify the specific microorganism that’s infecting you.
Despite the various tests available, here’s the hard truth about pneumonia: It’s challenging to diagnose. Blood cultures and sputum tests are often inconclusive; in the majority of cases, the offending pathogen isn’t identified, according to recent guidelines for pneumonia diagnosis and treatment from the American Thoracic Society and Infectious Diseases Society of America, published in the American Journal of Respiratory and Critical Care Medicine.
Plus the tests can take a few days to come back and in the meantime, you need to start getting better. So the doctor generally has to make his or her best guess as to what’s going on and what will best fix it. For this reason, some doctors don’t bother getting a sputum sample or a blood culture. Sometimes, it’s simply the fact that a medication is working (or not working) and you are improving (or not) that confirms whether the diagnosis was right and tells the doctor what to do next when it comes to treatment for your condition.
How Is Pneumonia Treated?
Unless your doctor determines that you need to be hospitalized (more on what would lead them to make this call below), you can probably recover from pneumonia at home with a combination of oral medication, rest, and self-care strategies. If your breathing is labored, your doctor might also prescribe breathing treatments (in which you inhale medication through a device called a nebulizer).
In theory, the oral drugs you get for pneumonia should be tailored to the cause—antibiotics if it’s a bacterial infection, and other meds (or no meds) if it’s viral. But in reality, don’t be surprised if the doctor gives you antibiotics even if he or she doesn’t know for sure that you have a bacterial infection. The experts we consulted said most doctors prescribe these medications—which include amoxicillin, doxycycline, azithromycin, and clarithromycin—for pneumonia across the board “just in case,” since even if you have viral pneumonia it can be followed by or accompanied by a bacterial infection. And as we mentioned above, often it’s not clear what the pathogen is, so antibiotics are used to cover the bases.
How Long Will I Be on Antibiotics for Pneumonia?
Traditionally, a course of antibiotics for pneumonia would be 10 days or maybe a week; but growing research suggests five days of the drugs can often knock out pneumonia (in both kids and adults) just as well as a longer course. For example, in a recent Canadian study in JAMA Pediatrics of 281 children with pneumonia, those who took amoxicillin for five days recovered comparably to those who took it for a full 10 days.
If the doctor determines that the flu (influenza) virus is causing your pneumonia, he or she might prescribe one of the same drugs given to flu patients, like Tamiflu (oseltamivir). These don’t kill the virus, but if they’re started within a few days of symptoms they can help slow the infection from spreading, which might make your illness shorter or less severe. Tamiflu is taken twice a day for five days.
If you’re diagnosed with COVID-19 pneumonia, talk with your doctor about which treatments make sense for you. In the rare cases where pneumonia turns out to be from a fungus, a doctor will probably prescribe an antifungal drug or possibly an antibiotic.
In addition to any formal treatments you get, these self-care strategies can aid your recovery or make you more comfortable while you get better.
Avoid alcohol. It weakens your immunity, the last thing you need right now.
Don’t smoke. It’s literally the worst thing you can do if you have pneumonia. Avoid secondhand smoke, too.
Ease coughing or a sore throat. Suck on lozenges or sip hot water with lemon and honey.
Loosen lung secretions. This makes them easier to cough up and spit out. The key to doing it is moisture: In addition to drinking plenty of fluids (see below), try using a cool-mist humidifier, taking a steamy shower, or sitting in a steamed-up bathroom.
Lower your fever. Over-the-counter (OTC) pain relievers like Advil or Motrin (ibuprofen), Aleve (naproxen), or Tylenol (acetaminophen) can all reduce fever. Follow the label directions, since taking too much of any of these meds can have risks. OTC pain relievers can also help ease a headache or muscle aches. Adults can take aspirin if they prefer. Aspirin should never be given to children.
Rest. It’s important to take it easy until your fever and shortness of breath subside. If needed, see if someone can help with meals or household chores for a few days.
Stay hydrated. Drink plenty of water and other fluids (check your urine color; it should be clear or light yellow). Kids might also need an electrolyte-replenishing drink like Pedialyte; ask your pediatrician.
Will I Need To Be Hospitalized?
If you’re very sick with pneumonia, or if pneumonia poses an extra-high danger to you (due to, say, your age or an underlying condition), you might need to be treated in the hospital. The groups most likely to fall into these categories are babies and young children, adults over the age of 65, people with weakened immune systems (due to HIV/AIDS, cancer treatment, or use of immunosuppressive medications, for example), and those with preexisting heart or lung disease. In the hospital, you will likely receive IV antibiotics, fluids, and supplemental (extra) oxygen, also called oxygen therapy. You might also get breathing treatments like the ones we mentioned earlier. As you recover, you can be switched from IV to oral antibiotics, which will enable you to go home sooner. People who are extremely sick with pneumonia sometimes need mechanical ventilation—that is, to be put on a ventilator.
How Can I Prevent Pneumonia?
The same steps that can help protect you from colds, flu, and coronavirus—which you should be a whiz at by now (thanks, 2020)—can also help you avoid pneumonia, which spreads similarly through respiratory droplets that are coughed into the air or onto surfaces. Wash your hands often with soap and water; if soap and water aren’t available, use a hand sanitizer with at least 60% alcohol. Disinfect “high-touch” surfaces like doorknobs and counters; stay away from people you know are sick; and avoid touching your eyes, nose, and mouth without first washing or sanitizing your hands. As always, don’t smoke, and stay away from secondhand smoke. Tobacco byproducts make you more susceptible to pneumonia and weaken your ability to fight the infection.
But these steps aren’t all you can do.
Vaccines for Pneumonia
There are not one but two vaccines that can help you ward off pneumonia. The first is your annual flu shot: It not only can prevent the misery of the flu but also can protect you from influenza’s potential complications, which include pneumonia.
If it’s recommended for you, you should also get one or both of the two available pneumococcal (pneumonia) vaccines, which protect against infection by Streptococcus pneumonia, also known as Pneumococcus. This nasty bug is the most common cause of bacterial pneumonia. About 400,000 people in the U.S. are hospitalized for pneumococcal pneumonia each year, according to the CDC, and 5% to 7% die from it. The pneumonia vaccine also protects you from meningitis and life-threatening blood infections (sepsis) that are caused by the same bacteria. It doesn’t protect you against any of the other types of pneumonia, though.
How Long Will It Take to Recover from Pneumonia?
Once you start treatment, you should experience improvement in your pneumonia symptoms pretty quickly, within 48 hours or so. But full recovery will take time. In general, you will probably feel better before you really are better; studies show people with pneumonia usually report improvement in their symptoms even before chest X-rays show positive changes. Remember to keep resting and take things slow while you are recovering. On average, it takes one to two weeks to get over viral pneumonia and 10 days to three weeks for bacterial. If you are older or have a chronic condition, recovery may take even longer. Even after the infection clears up, your cough may linger, and you may continue to feel tired for around a month.
Pneumonia can be scary and even life-threatening, but you can take comfort in this: Doctors have amassed a huge amount of knowledge about this illness and are learning more all the time. Once diagnosed, you have a very good chance of making a full recovery. Be patient, rest, and follow your doctor’s instructions to give yourself the best shot at feeling well again soon.
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