The Four Types of Pneumonia

A 1930 edition of the Real Physician's Creed.
It's now so huge it's non-photogenic.

In medical school, most physicians learn from the Real Physician's Creed, which by now is about 300,000 pages and still growing. I only found out about it because one physician is a friend of mine who used to be a respiratory therapist. But he is now retired, so he has given me permission to release some of the contents thereof.

On page 304,403, of edition 4,432, is a note describing the three types of pneumonia.  Listed they are as follows:

1.  Walking Pneumonia:  Don't have it but something must be ordered to make everyone happy.  

2.  Pneumonia.  They really have it and you can see it on the x-ray and everything.  Or, as noted, sometimes you can hear it via crackles before you can see it on x-ray.  Or, the white blood count is elevated, indicating there is an infection somewhere so it might be pneumonia.  It is generally lobal and caused by a bacteria. Treatment is antibioitic to treat the infection and systemic corticosteroids to treat the inflammation.  However, you may also treat it with ventolin because one study showed it enhances sputum production which, uh, somehow is twisted into making some doctors think it... well, it does help, errr, bring up the pneumonia... IT JUST DOES!!!

3.  Faux-pneumonia.  The patient doesn't have it, but you need a better diagnosis than walking pneumonia in order so that the patient may meet criteria.  You can see it on the x-ray only if you have the superior vision abilities only taught in medical school, which can be found on page 3,133 of the Creed.  (I at present do not have a copy of that page, as this part of the book I have has been destroyed by too many coffee stains).

4.  Double Pneumonia.  They have twice as much pneumonia than the average person who actually has a diagnosis of pneumonia, which some call real pneumonia as compared with faux pneumonia.  It is generally caused by a virus and is deadlier than regular pneumonia.  Treatment is to hit it with everything, including systemic corticosteroids to treat inflammation, antibiotic to treat the infection, ventolin to help the patient cough up the pneumonia, and anything else you feel like throwing at it. Usually it involves treating the symptoms.  Treatment is generally supportive.

Further reading:

1. The real physician's creed
2. 999 types of ventolin

Inhaled steroids don't cause pneumonia

Aha! Another fallacy debunked. Well, surely we are aware that this is one study, but the results of a recent study confirm that inhaled corticosteroids like Flovent or Pulmocort, or combination inhalers like Advair and Symbicort, do not cause pneumonia.

Yet, it is true that pneumonia is common among COPD patients, however the reason is not because these individuals are taking steroids. And sure steroids can knock down the immune system in your mouth slightly, thus causing thrush. Yet this minor side effect can be almost completely "washed" away simply by rinsing after each use.

Advair is said, according to most studies, to not cause any systemic side effects -- so long as you (ahem) rinse after each use. Thus, what causes pneumonia is not the inhaled steroids, but something else. Perhaps it's the fact that many COPDers have excessive phlegm trapped within their lungs, which creates a breeding ground for bacteria. This, I would suspect, causes most cases of pneumonia in COPDers.

The fact they are taking an inhaled steroids to reduce inflammation and prevent bronchospasm is not what is causing pneumonia. In fact, there have been many COPD patients over the years who were not on inhaled steroids, and they were equally likely to have pneumonia.

So, fallacy debunked? Perhaps. While we have common sense enough to know this is just one study, we also have common sense enough to not believe every little rumour about a new medicine that comes around.

The truth is, there are many people who don't take medicine their doctor prescribes to treat their lung diseases out of fear of side effects from the medicine. As an asthmatic and a person who's used inhaled corticosteroids for over 30 years to treat severe asthma, I can honestly state that the risks of not taking your COPD/asthma medicine are far worse than the risks of the medicine itself.

In fact, I think we ought to make this RT Cave #38:

RT Cave Rule #38: The risk of not taking asthma and COPD medicine is far worse than the risks of the medicine taken to treat these diseases.

An epidemic of Fake Pneumonia

It's spreading hospital to hospital, patient to patient, faster than any disease on the market. Would you believe the disease I'm referring to doesn't even exist. In fact, it's not even contagious.

I'm sure all nurses and RTs have seen it: it's fake pneumonia.

Fake pneumonia: Patients that are diagnosed with pneumonia, but there is nothing on the chart to indicate pneumonia. The x-ray and labs look normal. Auscultation reveals clear lung sounds. When the patient is asked, he or she indicates no trouble breathing. The patient says something like, "I've never been short of breath in my life."

(Click here to check the signs and tests that indicate real pneumonia)

So why the diagnosis of pneumonia. I can only make guesses here.

1. The doctor had no clue what was wrong, so he chose the most common diagnosis


2. Pneumonia is the most reimbursable diagnosis.


3. The pt looked bad, but otherwise didn't meet criteria for admission.


4. The doctor actually thought the patient had pneumonia.
5. The patient is a lot of work for a family member, and they need a break
6. There really is no reason.

And, in order to meet criteria for admission, all pneumonia patients must have Q4 breathing treatments ordered. If they are not sick enough to have breathing treatments, they are not sick enough to be admitted.

Fake pneumonia is very contagious. You cannot get it by person to person contact. You can only get it from your doctor. So be wary.

That is, unless you want to be admitted. If that's the case, see a participating* doctor near you.

*Note: Not all doctors in your area will paritcipate in this program.