Can You Help To Prevent Another Pneumonia?

Dear Dr. Mahler: I have had at least three episodes of pneumonia over the past nine months. I was in the hospital for four nights in August, and find that it takes a long time to recover. Is there anything that I can do prevent another chest infection? I get yearly flu shots and had the pneumonia shot two years ago. I take Spiriva and Advair for my COPD. Carl from Longmeadow, MA Dear Carl: Even one episode of pneumonia is a concern for many of those with COPD. Not only do you feel sick, but it can sometimes take weeks to months to recover completely. To prevent another pneumonia, testing is necessary to check for two conditions associated with recurrent pneumonia – bronchiectasis and immunodeficiency. Bronchiectasis is abnormal stretching and enlarging of breathing tubes. It is usually caused by pneumonia. Mucus can build up in the abnormal breathing tubes and allow bacteria to grow. Over time, the bacteria can multiply causing recurrent pneumonia. One symptom is coughing up yellow or green mucus most days. Bronchiectasis is diagnosed by a CT scan of the chest.
One cut of CT scan of the chest showing cystic bronchiectasis changes (lower left)

One cut of CT scan of the chest showing cystic bronchiectasis changes (lower left)

Over time, bronchiectasis can cause pneumonia.

Normal breathing tube (top right) and bronchiectasis with green mucus inside breathing tube (bottom right).

Our body’s immune system fights infection. However, the ability of our immune system begins to decline at about 50 years of age. Obesity, alcoholism, and drug use may contribute to poor immune function. Low thyroid function and low Vitamin D levels are also more common in the elderly. Our immune system may also be affected by not enough rest and sleep. Common variable immunodeficiency, abbreviated CVID, is the most common type of immunodeficiency. Individuals have repeated infections usually in the chest as a direct result of low levels of immunoglobulin G (IgG) in the blood. These low levels do not adequately protect against bacteria. A blood test can be ordered to make the diagnosis. I suggest that you ask your doctor about checking for both bronchiectasis and CVID because there are treatments for both of these conditions. An inhaled or oral antibiotic is used to treat bronchiectasis. For CVID, intravenous immunoglobulin (IVIG) is given through a plastic tube into a vein usually every 4 weeks to boost your ability to fight infection. You may also ask your doctor to check your thyroid gland function and to measure your Vitamin D level in the blood. Another possible cause for pneumonia is the use of an inhaled corticosteroid (this is one of the medications in Advair). It is my practice to recommend a trial of stopping the inhaled corticosteroid if you have repeated pneumonias. This means stopping your Advair and replacing it with a long-acting beta-agonist bronchodilator such as formoterol, indacaterol, or salmeterol (the other medication in Advair). Finally, you should make sure to use good hand hygiene, use alcohol only in moderation, and get plenty of sleep. Donald A. Mahler, M.D.

Donald A. Mahler, M.D. is Emeritus Professor of Medicine at Geisel School of Medicine at Dartmouth in Hanover, New Hampshire. He works as a pulmonary physician at Valley Regional Hospital in Claremont, NH, where he is Director of Respiratory Services.