The Stupid Question: How Does A Relatively Healthy Person Die Of Pneumonia?
Only weeks after ethereal British electronic pop duo Broadcast toured Australia and appeared at the Meredith Music Festival, their vocalist Trish Keenan has died. After two weeks in intensive care, she succumbed to complications of pneumonia last Friday morning, UK time, aged 42.
Pneumonia is the kind of disease we associate with Dickensian match girls, romantic novel protagonists who get caught in the rain, old and frail people, or members of remote indigenous communities. It’s sad and shocking that despite the advances of modern medicine, someone can still die of it in a post-industrial city. So, time for a Stupid Question: how can pneumonia kill someone in their prime?
While Trish Keenan’s death was unexpected, sadly it’s not unusual. According to the British Medical Journal, approximately six in every thousand Britons aged 18-39 will suffer from pneumonia each year. Between 20 and 40 per cent of sufferers will require hospitalisation, and between five and ten per cent will require critical care.
If you become that ill, your outlook is not so good; the mortality rate in the United Kingdom is around the same as the critical care rate – five to ten per cent. Pneumonia is the fourth most common cause of death in the UK.
While the Medical Journal of Australia points out that we lack detailed statistics on the incidence and fatality of the disease, things are definitely grimmer in the United States, where pneumonia mortality rates average 14 per cent… and are getting higher. However, it’s only the sixth biggest killer in the US.
To find out how some people throw pneumonia off but others die from it, The Enthusiast did what sick people do: we consulted a doctor working in the Melbourne hospital system, whom we’ll call Rebecca.
What we’re discussing, Rebecca explains, is what’s commonly called ‘community-acquired pneumonia’. “This refers to people who did not pick up their pneumonia in hospital.” Symptoms include coughing, fever, chest pains and shortness of breath. It can be caused by either a bacterial or a viral infection; bacterial pneumonia can be treated with antibiotics, while antiviral medications, administered early, can help viral pneumonia.
“Pneumonia develops when the virus ‘takes hold’ in the lungs – there is a big focus of infected tissue in the lungs causing damage and build-up of inflammatory fluids in the airspaces,” says Rebecca. “This occurs when the battle between the virus – which enters through the mouth, throat, nose – and the immune system is won by the virus in the lungs.”
If a patient deteriorates to the point where he or she can’t breathe unassisted, a breathing tube is inserted down the throat and a ventilator mechanically helps the patient breathe. And if a patient goes into acute respiratory distress, there is extracorporeal membrane oxygenation (ECMO), in which a device similar to a heart-lung machine takes over the lungs’ role of oxygenating blood. A relatively new technology, ECMO is the most extreme life support available. “It is used as an absolute last gasp – ha ha – in patients who are near to death,” says Rebecca, “and sometimes it saves their life.”
There are two main ways you can die of pneumonia. “Respiratory failure, which is basically your lungs filling with fluid and no longer being able to work. Or overwhelming sepsis – the infection is coursing through your bloodstream, which makes your blood pressure drop. So you go into cardiac arrest and die.”
Medical convention is that bacterial pneumonia is more severe, but Rebecca says that isn’t always the case. Trish Keenan’s pneumonia was viral – news outlets reported that while on tour, Keenan had contracted H1N1 influenza, otherwise known as swine flu.
“H1N1 is quite an interesting virus as it did not cause the predicted epidemic, however it did make many young people very, very, intensive care-style sick,” says Rebecca. “I worked in ICU during Swine-o-Rama ’09, and at one stage we had four intubated patients between the ages of 17 and 25.”
Intriguingly, a recent Medical Journal of Australia article showed that older people, who were more likely to have been exposed to another, similar strain of influenza, had developed antibodies that worked against H1N1 as well. “The older the person was, the more likely they were to have these protective cross-reactive antibodies. This would also explain why young people seem to be particularly affected [by H1N1],” says Rebecca.
In a letter to the MJA in January 2010, four eminent Australian ICU specialists pleaded that the medical community not become complacent about the risks of death from H1N1. They pointed out that during the 2009 outbreak, intensive care admissions for viral pneumonia had increased 15-fold compared to a normal winter, and the use of ECMO had increased 17-fold.
However, the likelihood of contracting pneumonia, and the disease’s severity, also depends on a number of different factors, says Rebecca: “the virulence of the virus; the patient’s general immune system; and also the lung’s own specific defences.”
Anyone with a compromised immune system – for instance, a cancer or AIDS patient – is more likely to get pneumonia. So is someone whose cough reflex isn’t working properly, so airway secretions are inhaled rather than being cleared. “This can occur in neurological diseases like Parkinson’s disease or muscular dystrophy,” says Rebecca. “It occurs commonly in drunks or people who overdose, and vomit whilst unconscious. It can also occur during anaesthesia.”
Jean-Dominique Bauby, the French author of The Diving Bell and the Butterfly, died of pneumonia, a complication of his Locked-in syndrome. Allen Collins, the Lynyrd Skynyrd guitarist who was rendered paraplegic in a car crash, also died of pneumonia complicated by his paralysis.
Smoking also contributes to pneumonia, in part because tobacco smoke paralyses the cilia – “the little hairs that line the airways, that continuously rhythmically beat upwards, pushing any bugs or particles that fall in towards the lungs back upwards.” Actor George Peppard’s two-pack-a-day habit was a contributing factor in his death from pneumonia.
“That said, often people without any identifiable risk factors develop pneumonia,” says Rebecca. It has claimed the lives of James Brown, Bernie Mac and Jim Henson. French actor Guillaume Depardieu died of pneumonia at the age of 37; it killed Brittany Murphy at age 32. In a sad case in 2005, actress Nicole DeHuff, 30, was turned away from hospital twice before her pneumonia was correctly diagnosed, too late to save her life.
RIP Trish Keenan, the latest victim of an all too common killer.
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