Pulmonary hypertension and pneumonia

Pulmonary hypertension (PH) is a disease characterized by high blood pressure in the blood vessels, called the pulmonary arteries, responsible for transporting blood from the heart to the lungs. Pneumonia, meanwhile, is an infection that affects one or both lungs.

PH and pneumonia are linked: PH can negatively affect lung function, increasing a person’s risk of developing conditions that affect the lungs, including pneumonia. Both are serious conditions, and pneumonia may require emergency medical care. A progressive disease, PH makes the heart have to work harder to pump blood through the lungs.

Anyone with signs of respiratory illness should seek medical attention.

Some common symptoms of pneumonia are:

• cough
• fever
• chills
• chest pain when breathing or coughing
• fatigue
• nausea
• confusion, especially in older adults

Read on to learn more about the connection between PH and pneumonia, the risks associated with each, and how doctors manage and treat pneumonia.

Development and diagnosis

A rare disease, PH can compromise the heart and lungs, making the lungs more susceptible to additional lung disorders and infections.

PH and pneumonia can make each other worse. People admitted to the hospital with both conditions have a significantly higher mortality risk than the general public.

Chronic or severe lung conditions, such as PH, can make it harder to fight a chest infection, because the body is already compromised by increased inflammation. If an infection such as pneumonia occurs, inflammation spikes even further, which can increase the immune system’s sense of threat. This can harm nearby organs and tissues.

At the same time, lung damage from pneumonia can either cause PH or make it worse. Guidelines from the European Society of Cardiology (ESC) and European Respiratory Society (ERS) classify this as Group 3 PH, in which chronic scarring, tissue loss, and low oxygen levels in the lungs cause progressive blood vessel damage and increase pressure on the heart.

How pneumonia makes PH worse

If blood pressure in the lungs is already high, pneumonia can place even more pressure on the lungs and heart.

It can do so in the following ways:

1. Inflammation and protein-rich fluid flood the tiny sacs in the lungs called alveoli, reducing how much oxygen is transferred between the lungs and blood vessels. This can drive up the blood pressure in the lungs.
2. The lungs attempt to increase oxygen uptake by narrowing blood vessels near oxygen-depleted alveoli, thereby diverting blood flow toward areas with better oxygenation. If an infection such as pneumonia is damaging the entire area, blood vessels constrict throughout the lung’s vascular network.
3. The combination of many blood vessels narrowing at once, along with increased swelling, tiny clots, and external pressure from fluid buildup, causes blood pressure in the lung’s arteries to dramatically rise. This causes sudden PH.
4. The right side of the heart has to pump against this sudden increase in resistance and risks being overloaded and strained, which can result in right heart enlargement and right heart failure.

This danger is especially critical in a heart already experiencing the strain of preexisting PH.

Comparing PH and pneumonia

Being aware of pneumonia symptoms can help people with PH to act quickly in a potential crisis.

The table below shows the symptoms unique to pneumonia and those that both pneumonia and PH can cause.

Anyone experiencing these or other abnormal symptoms with PH and pneumonia should consult a physician.

Preventing pneumonia with essential vaccines

Pneumonia can trigger a more significant emergency in people with PH. However, annual pneumococcal and influenza vaccines have shown good effectiveness in reducing the risk of complications and overall mortality in vulnerable people.

For those with PH, a pneumococcal vaccine and an annual flu vaccine are highly recommended to reduce the risk of pneumonia. People with PH can ask their healthcare team which vaccines will best reduce the risk of common viral infections.

Mortality and risk

PH can make pneumonia more likely to be fatal. An analysis of a nationwide hospital registry found that patients in the hospital with pneumonia and PH had an in-hospital mortality rate of mortality rate of 8.9%, compared with a 5.8% risk of mortality for those in the hospital with just pneumonia.

For this reason, early detection and proper treatment can be life-saving in those with pulmonary hypertension and pneumonia.

The infection risk of intravenous PH treatment

Many people with PH need continuous administration of medications through an intravenous, or into-the-vein, drip using a central line catheter — meaning the medicines go directly into a main vein. While vital for PH management, this also carries a risk of catheter-related bloodstream infections (CRBSIs). Research has found that approximately 92% of people with such infections need to stay in the hospital for treatment.

Tiny infected blood clots from the catheter can break away, travel through the heart, and become trapped in the lungs’ blood vessels. These are called septic pulmonary emboli.

This supplies bacteria to the lung tissue from the inside, which can cause pockets of infection called lung abscesses and severe inflammation that can closely resemble pneumonia on a scan. It can also cause symptoms similar to pneumonia, such as fever, chest pain, shortness of breath, and cough.

Patients developing these symptoms while on an intravenous pump for PH should talk with their doctors about requesting tests for CRBSI.

Why children face higher risks

Infants and children with PH have exceptionally sensitive and reactive pulmonary blood vessels. In pediatric pulmonary hypertension, pneumonia can be dangerous.

When a child develops a lower respiratory infection such as pneumonia, less blood reaches the lungs, causing the heart to beat faster and blood vessels to be constricted.

This triggers what doctors call a pulmonary hypertensive crisis. This is a sudden, life-threatening lung pressure spike that can cause fainting, a dangerous drop in blood pressure, and heart failure. Pulmonary hypertensive crisis can be fatal.

Because of this hyper-reactive response, children with PH who have pneumonia typically need close monitoring in a hospital setting. PH symptoms might also mirror those of pneumonia in children, which can mask the condition and delay vital treatment.

Treatment and prognosis

When doctors manage pneumonia in a person with PH, they will balance the need to clear the infection with the need to prevent acute right heart failure.

Treatment will involve the following:

• a rapid diagnosis of pneumonia and targeted treatment, such as antibiotics in the case of bacterial pneumonia, before the infection can place too much strain on the cardiovascular system
• supplemental oxygen to treat low blood oxygen levels, which helps relieve stress on blood vessels in the lungs and prevents unnecessary pressure on the right side of the heart
• continuing and closely monitoring PH medications, such as tablets, inhaled medications, or intravenous infusions, as these are critical for maintaining open blood vessels in the lungs
• monitoring for fluid overload and using diuretics when possible to ease the workload on the right side of the heart as people with PH require extreme caution around fluid balance

Having an emergency plan in place

For people with PH, it’s important to have an emergency plan in place in the event that an acute respiratory illness such as pneumonia develops. Having an action plan ensures that patients and their caregivers can recognize warning signs early and take immediate action.

The following steps are key for people who develop pneumonia with PH as an underlying condition.

Call emergency services when needed

Those with PH should be on the lookout for symptoms indicating that the right heart cannot pump enough blood, that pulmonary pressure has increased, or that they may have pneumonia. PH patients should call emergency services immediately if they experience the following:

• fainting or sudden blackouts
• severe breathlessness while at rest
• high fever
• chills
• coughing up discolored or bloody mucus
• confusion, altered mental state, or drowsiness
• sudden chest pain or heavy pressure on the chest
• blue-tinted lips or fingers, cold or clammy skin, confusion, or severe light-headedness, which can all indicate shock or poor circulation

For people with PH on a continuous IV or subcutaneous (under-the-skin) pump, emergency services should be contacted immediately if there are any of the following signs or symptoms:

• sudden fever and chills for those with a central line catheter
• a pump malfunction
• a catheter blockage
• a line disconnection

Establish oxygen support

When pneumonia causes oxygen levels in the lungs to drop, lung blood vessels tighten. This forces the right heart to work harder. The following steps should be taken to maintain oxygen levels:

• If home oxygen is available, it should be used to keep blood oxygen saturation within the target range prescribed by the patient’s PH team.
• If oxygen levels continue to fall despite home oxygen, seek emergency care immediately. Note thatupplemental oxygen does not treat the underlying pneumonia or right heart failure, although it can widen blood vessels.
• Paramedics should be informed immediately that the patient has pulmonary hypertension so they avoid using high airway pressures during breathing support, as such measures can impair blood returning to the heart.

Manage routine medications

Patients must never stop or skip the medications they take to control PH or any intravenous or subcutaneous pumps. An interruption of even a few minutes can be life-threatening.

Alert the patient’s PH care team as soon as pneumonia is suspected

Patients should contact their PH specialist center as soon as pneumonia is suspected, or have a caregiver do it for them.

When headed to the emergency room, ensure the patient or a caregiver is carrying an emergency card or a letter confirming the PH diagnosis. It’s also important to have available the patient’s oxygen requirements and the specialist PH team’s 24-hour phone number.

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