By Christopher M. CIRINO, DO MPH
Your Health Forum
Sir William Osler, one of the founders of modern medicine, used to refer to pneumonia as “the Captain of the men of death” and “friend to the aged”, relating to the often acute precipitation of death, “protecting them from the colds of degradation”.
Pneumonia is not an uncommon illness that often may require hospitalization. Now that we are in the flu season, I wanted to include a post on how to protect yourself from pneumonia. In the patients that I have evaluated, the pain that they experienced from pneumonia has left an indelible impression on me. Each year, I am saddened to see that several patients are unable to recover despite antibiotics and supportive care and ultimately succumb.
Pneumonia increases with age, and it is no coincidence that rates increase from 1 in 1,000 in the general population to 18 in 1,000 in those older than 65 years of age and up to 52 cases per 1,000 in those at least 85 years of age (Jackson et al, 2004). The rates of hospitalization and mortality are also much higher in the elderly, with a four-fold increase in hospitalization; the majority of deaths from influenza and pneumonia occur in age 65 and older ( compared to those in the 45-64 age range (Marston et al, 1997). Although we cannot change the chronology of aging – yes it is better than the alternative – we may be able to modify some of the risk factors of pneumonia and other infectious diseases and protect ourselves as we age.
Topics to be discussed: The influence of lung structure and function on pneumonia, the risk factors of age and pneumonia, and 6 ways you can prevent yourself from getting pneumonia.
Pneumonia and structure and function
The lungs are branching structures with multiple iterations until the microsopic alveoli sacs are reached, where gas exchange occurs. This is characteristic of a natural fractal. An incredible fact about our lungs is that they contain 1,500 miles of airways and up to 300 to 500 million alveoli! This expansive lung surface area with its angulations work to displace a direct insult to one area by an inhalant or particulate matter, mitigate the risk of aspiration, adapt to airway recruitment with increased demand, and function in concert for removal of particulate matter or microbes.
The alveoli can become inflamed from a viral infection, aspiration (for example, getting a small amount of gastric acid in the lungs) or from airways hypersensitivity, such as with an asthma exacerbation. Bacteria can enter the airways either in small respiratory droplets that are inhaled or aspirated. Inflammation ensues and leads to trapping of propagating bacteria in the lower airways. This leads to greater inflammation – ultimately reaching a tipping point and causing acute pneumonia.
At the time a person develops pneumonia, they may have a high fever, productive cough, chest pain, usually localized to the base(s) in bacterial lobar pneumonia. Findings can be abrupt with bacterial pneumonia, such as Streptococcus pneumoniae or Staphylococcus aureus. They are usually less severe with a more prolonged course in pneumonia caused by Mycoplasma or Chlamydophyla pneumoniae. A radiograph will demonstrate infiltrates usually in the lower lobes in the former; in the later, a radiograph will show patchy, tissue (“interstitial”) reticular (or “lacey”) changes.
Radiograph of a severe multilobar pnuemonia caused by Streptococcus pneumoniae
Same patient as above with CT scan showing “air bronchograms” – outlining of bronchioles by surrounding diseased tissue
Changes that Increase Risk of Pneumonia with Aging:
Lung Structural and Mechanical changes: There are structural changes that occur with aging that may lead to an increased risk of pneumonia. The lungs have a mucus layer and cilia, which assist in protecting the lung space from invasion and mobilizing the secretions in a cough. There are also changes in the mechanics of the rib cage in aerating the lung and providing the negative pressure needed to more easily deflate and clear the lungs.
Aspiration: There is also an increased risk of aspiration when we age – both large (macro-aspiration) and small particle (micro-aspiration). Swallowing may be altered by changes in the oropharynx (mouth/throat) or in the esophagus, leading to an increased risk of aspiration. The mouth becomes drier and risk for cavities increase. Changes in consistency of food may be necessary, otherwise a person is at increased risk for choking. To make matters worse, the cough reflex is blunted in advanced age.
Immunosenescence: As with all other aspects of our bodies, the immune system also changes as we age, including all lines – the innate immunity, humoral immunity and cell-mediated immunity. Lymphatic structures, the spleen and bone marrow become less potent. This results in a relative decrease in activity and production of defenses, such as natural killer cell activity, antibodies (e.g. respiratory IgA antibodies), antigen processing and clearance of bacteria by macrophages, and increased risk for bacteria with capsules, such as Streptococcus pneumoniae and Haemophilus influenzae.
How to Prevent Pneumonia
Below is a list of recommendations by an infectious disease specialist in how to stay safe from getting pneumonia, or protect yourself from another bout.
A yearly influenza vaccinations may not afford complete protection from acquiring influenza, but it has a likely rate of protection of 30-50%, from influenza depending on the vaccination selection for the influenza strains for that year. The newer influenza vaccination may afford better protection, as indicated by a better measured immune response after vaccination, when compared to the usual options. Remember by reducing the risk of influenza (which can cause a “pneumonitis” or inflammation of the airways), it will reduce the risk of lung tissue inflammation that can predispose to bacterial pneumonia, such as Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae.
Other vaccinations that would be useful are the PREVNAR (PCV 13) and the PNEUMOVAX (PPSV23), which are conjugate and polysaccharide vaccinations, respectively, that afford some protection against Streptococcus pneumoniae.
How effective are they together? In a large-cohort study of Swedish patients >65 years of age, the “additive effectiveness” of influenza and pneumonia vaccination was approximately a 29% reduction in all-cause pneumonia and a 35% reduction in the death rate from all-cause pneumonia compared to the non-vaccinated groups.
It might also be a good time to get the vaccination for Haemophilus influenzae b, although there are no specific recommendations for vaccination in this age group.
2. Get Enough Sleep
Sleep efficiency drops as we age. This can lead to changes in our body’s mechanism of immunity as well. Studies have shown disturbances in the function of the innate (Natural killer cells) and adaptive immunity (T-cells and B-cells) with lack of sleep. Getting the right amount of sleep (approx 8 hours nightly) will protect you. If you are having difficulty with sleep, please review a prior post on sleep hygiene and recommendations for evaluation.
3. Keep acid reflux under control and protect yourself from aspiration
Studies suggest that up to 15% of cases of pneumonia are related to aspiration, an ingestion of oral secretions or gastric acid and contents into the airways. The incidence of aspiration pneumonia is higher in older age (Teramoto et al, 2008). Cough reflex and oropharyngeal and esophageal motility are also altered as we age. Eating slowly, ensuring that food is well-chewed and avoiding behaviors that can trigger acid reflux will protect you from aspiration, which will protect you from pneumonia.
4. Limit alcohol, smoking and vaping
Alcohol creates a host of problems with our mechanical clearance and our immune system and represents a significant risk factor to pneumonia and oropharyngeal colonization with Klebsiella pneumoniae. Alcohol impairs our gag and cough reflexes and can exacerbate acid reflux-associated microaspiration.
Our innate immunity, associated with alveolar macrophages and anti-bacterial proteins produced (e.g. chemokines), are suppressed from alcohol. Even lymphoid tissue, which plays a role in activation of our acquired immunity (T-cells) is altered. These impaired mechanisms can strain the body’s ability to respond to an infection, and lead to more overwhelming, life-threatening manifestations of pneumonia.
Smoking is clearly linked to airways sensitivity and impairment of the ciliary clearance mechanisms of our bronchi. Smoking not only increases the risk of getting pneumonia (Odds Ratio =2 – this means a two-fold higher risk) but also the risk of death from pneumococcal pneumonia. When smokers quit, the risk of pneumonia decreases by 50% after 5 years.
As of way of curbing vaping in adolescents in Oregon, the Governor approved of a ban to be effective Oct.15 on all flavored vaping products – (though it has been halted as of Oct. 17). This is because of a spate of cases, now more than 1,500 people in the United States, that were diagnosed with Vaping-Associated Lung Injury (VALI). If you are interested in reading more about this, See the Harms of Vaping post.
5. Keep exercising
A rolling stone gathers no moss. The same can be said about the importance of activity. Exercise leads to increase respiratory mechanics and lung expansion, which reduces the risk of collapse of alveolar sacs, or atelectasis. There may also be a more robust immune system in those who exercise. In one study of women who exercise and walk more frequently, they were less likely to develop pneumonia (18% lower risk). Another study showed an increase in natural killer and T cells in men who were involved in a moderate exercise program. Here it is – another good reason to exercise!
6. Optimize weight to protect or mitigate risks of pneumonia caused by Chronic Diseases such as Diabetes mellitus
Maintaining a healthy weight and avoiding obesity will protect you from the metabolic syndrome diagnoses, including diabetes, high blood pressure (hypertension), sleep apnea, as well as reduce the risk of reflux (heartburn)-associated aspiration. Obesity was found to be a unique risk factor for influenza disease severity during the 2009 H1N1 flu pandemic. A person who is obese (with a BMI between 30 and 34.9) has approximately 40% increased risk of pneumonia compared to someone with a healthy weight; someone with severe obesity (BMI >35) had a two-fold risk. A diabetic has a three-fold (i.e. 300%) higher risk of developing pneumonia and more likely to have a more severe presentation.
Other: Refer to the post on Wellness and Infection Prevention tips. This includes social distancing from other that are ill, hand-washing, dental hygiene and avoiding or limiting medications that can be harmful to the immune system.
Maintaining optimal health has benefits in protection from infection. There are several ways that one can follow the goal of a long and healthy life (lifespan and healthspan). As we gain a greater understand of the immune system, we learn that our risks are more mutable than we once had thought – that health and illness are not merely left to the fates.
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