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Pneumonia is an infection that inflames the air sacs of one or both lungs, often filling them with fluid. It typically causes cough, fever, breathlessness and chest pain, and can range from mild to serious. Most cases are treated with antibiotics (for bacterial causes), rest and fluids, while some people need hospital care and oxygen. Recovery can take several weeks, and gently staying active as you improve helps the lungs recover. This page covers how pneumonia is recognised, treated and recovered from.
Definition
Pneumonia is an acute infection of the lung parenchyma. It is classified by setting of acquisition: community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and pneumonia in the immunocompromised host. Aspiration pneumonia is a separate but overlapping entity.1
Pathophysiology
Pneumonia occurs when an infectious organism reaches the lower airways and overwhelms host defences (cough, mucociliary clearance, innate and adaptive immunity). Alveolar inflammation produces consolidation, impaired gas exchange and the clinical syndrome of fever, cough, sputum and dyspnoea. Hypoxaemia may occur through V/Q mismatch and shunt.
Co-morbidities and risk factors
Risk is increased by older age, smoking, chronic lung disease (COPD, bronchiectasis, asthma, IPF), heart failure, diabetes, immunosuppression, alcohol misuse, neurological conditions predisposing to aspiration, malnutrition, and recent hospitalisation or antibiotic exposure. Aboriginal and Torres Strait Islander people experience higher rates of severe pneumonia.
Prevalence
Pneumonia is among the most common reasons for hospital admission in Australia and a leading infectious cause of death, particularly in older adults. Incidence increases sharply with age and with the presence of chronic conditions.
Causes
The most common causes of CAP in Australian adults are S. pneumoniae, H. influenzae, atypicals (Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella spp.), respiratory viruses (influenza, RSV, SARS-CoV-2, parainfluenza), and S. aureus. HAP and VAP have a different microbiology (Gram-negative bacilli, multidrug-resistant organisms). Aspiration pneumonia involves oral flora and anaerobes.
Symptoms
Typical features include fever, productive cough with purulent sputum, pleuritic chest pain, dyspnoea, tachypnoea, and systemic features (myalgia, malaise, anorexia). Older adults may present atypically with confusion, falls, functional decline, or decompensation of a chronic condition, with relatively little fever or cough.
Severity assessment
Severity scores guide site-of-care decisions. CORB (confusion, oxygen saturation <90%, respiratory rate ≥30, systolic BP <90) and SMART-COP (predicting need for intensive respiratory or vasopressor support) are commonly used in Australia. CURB-65 and the Pneumonia Severity Index are also widely used internationally.2
Diagnosis
Importance of a diagnosis
Prompt and accurate diagnosis enables appropriate antimicrobial therapy, severity assessment, site-of-care decisions, and identification of complications. Delayed treatment increases mortality, particularly in severe pneumonia.
How is it diagnosed?
Diagnosis is based on the presence of an acute lower respiratory tract syndrome plus radiological evidence of new infiltrate. Microbiological investigations identify the pathogen in a minority of cases. In primary care, diagnosis is largely clinical, with imaging used when severe disease is suspected or the diagnosis is uncertain.
Radiology
Chest X-ray is the standard initial investigation, showing consolidation, lobar opacity, or multifocal change. CT is more sensitive and is indicated when diagnosis is uncertain, when complications are suspected (effusion, empyema, abscess, necrotising change), or in immunocompromised patients. Resolution of radiological change can lag behind clinical recovery by weeks.
Lung function and gas exchange
Pulse oximetry is part of the initial assessment of every patient. Arterial blood gases are performed in severe disease. Spirometry is not part of acute diagnosis; in patients with persisting symptoms after recovery, post-pneumonia lung function testing may identify previously unrecognised chronic lung disease.
Microbiology
Sputum Gram stain and culture, blood cultures (in moderate–severe disease), nasopharyngeal swabs for respiratory virus and atypical PCR, urinary antigen testing (S. pneumoniae, Legionella), and pleural fluid analysis where effusion is present. Empirical antibiotic therapy should not be delayed while awaiting results.
Investigations for predisposing factors
Recurrent or unusual pneumonia warrants investigation for an underlying cause: structural lung disease (bronchiectasis, lung cancer, foreign body), immunodeficiency, aspiration risk, or environmental exposure. HRCT and immunology investigations may be required.3
Management
Management and goals
Goals are: prompt eradication of infection, restoration of oxygenation, prevention and management of complications, support of co-morbidities, and full functional recovery. Recovery often extends well beyond hospital discharge, particularly in older patients.
Treatment options
Treatment is based on severity, setting and likely organism:
- Empirical antibiotics (per Therapeutic Guidelines: Antibiotic) — narrowed once the organism is identified.
- Oxygen therapy to maintain target SpO₂ (88–92% in those at risk of hypercapnia; 92–96% otherwise).
- Adequate hydration and nutrition.
- Early mobilisation and physiotherapy.
- Airway clearance where there is productive cough or retained secretions.
- Treatment of complications (effusion, empyema, sepsis, ARDS).
- Vaccination for prevention (influenza, pneumococcal, COVID-19, RSV).4,5,6
Identifying complications and deterioration
Worsening dyspnoea, persistent fever beyond 72 hours of appropriate antibiotics, increasing oxygen requirements, new pleuritic pain, or systemic deterioration should prompt review for complications: parapneumonic effusion, empyema, lung abscess, ARDS, septic complications, or treatment failure requiring antibiotic change.
Discharge and recovery plan
A discharge plan should include: clear instructions on completing antibiotic therapy, a follow-up plan (GP review at 2 weeks; chest X-ray at 6 weeks in selected patients to confirm resolution and exclude underlying malignancy), graded return to activity, smoking cessation support, vaccination, and rehabilitation referral when there is significant deconditioning. Many patients require weeks to months for full recovery.
Medications
Medications for pneumonia
Antibiotic selection follows the Australian Therapeutic Guidelines: typically amoxicillin or amoxicillin/clavulanate with doxycycline or azithromycin in mild–moderate CAP; benzylpenicillin plus doxycycline or azithromycin in moderate hospitalised CAP; broader cover in severe CAP. HAP and aspiration pneumonia have specific regimens. Empirical therapy should be narrowed when an organism is identified.
Correct use of medications
Patients should complete the full course of antibiotics, take them at appropriately spaced intervals, and seek review if symptoms worsen or fail to improve after 48–72 hours. Concurrent prescriptions for analgesia, antipyretics, and bronchodilators (in those with airway disease) should be reviewed for interactions and adherence.
Order of medications and rehabilitation
During acute illness, the principal priorities are antibiotic therapy and oxygenation. As recovery proceeds, the focus shifts to airway clearance (where indicated), early mobilisation, and progressive reconditioning. Physiotherapy is integrated throughout, from acute care to community rehabilitation.
Multi-system manifestations
Sepsis
Severe pneumonia is a common cause of sepsis. Recognition (qSOFA, NEWS, lactate) and time-critical management (cultures, antibiotics within 1 hour, fluids, source control) are essential. Survivors of sepsis frequently experience prolonged physical and cognitive sequelae.
Parapneumonic effusion and empyema
Up to 40% of patients with pneumonia develop a pleural effusion. Most are simple and resolve with antibiotics; complicated effusions and empyemas require drainage and prolonged antibiotic therapy.
Post-pneumonia syndrome
Persistent fatigue, breathlessness, cough, and reduced exercise tolerance are common for weeks to months after pneumonia, particularly in older patients and after severe illness. Structured rehabilitation accelerates recovery.
Decompensation of chronic disease
Pneumonia can decompensate underlying COPD, heart failure, diabetes, and other chronic conditions. Holistic post-discharge review should reassess all co-morbidities, not only the lung infection.
COVID-19 and long COVID
SARS-CoV-2 pneumonia produces a recognisable spectrum of acute and persisting consequences (long COVID), including fatigue, breathlessness, cognitive change, and reduced exercise capacity, even after apparently mild illness. Multidisciplinary rehabilitation is the cornerstone of management.
Living after pneumonia
Nutrition
Energy and protein requirements are increased during recovery. Many patients lose weight and muscle mass during hospitalisation. Early dietetic input prevents prolonged deconditioning and supports immune recovery.
Sleep
Sleep is frequently disturbed for weeks following pneumonia. Sleep hygiene, treatment of cough and breathlessness, and screening for OSA (where appropriate) support recovery.
Travel
Air travel is generally deferred until clinical recovery is well established and oxygenation is stable. Patients with significant residual symptoms or hypoxaemia should have an in-flight oxygen assessment.
Prognosis
Most healthy adults recover fully within weeks. Older patients and those with co-morbidities have higher short- and long-term mortality, even after hospital discharge. Long-term cardiovascular events are increased in the year following severe pneumonia, supporting holistic post-discharge follow-up.
Anxiety, depression and post-ICU sequelae
A significant minority of survivors — particularly after ICU admission — develop anxiety, depression, and post-traumatic symptoms (post-intensive care syndrome). Routine screening and access to psychological support should be part of rehabilitation.
Role of the physiotherapist
The physiotherapist supports recovery from pneumonia through airway clearance where there is a productive cough or retained secretions, early mobilisation, and exercise rehabilitation to counter the deconditioning that often follows a chest infection. They also teach breathing techniques and pacing, and educate on recognising slow recovery or complications.7,8,9,10
Warning signs
Part 1 · References
- Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official ATS/IDSA clinical practice guideline. Am J Respir Crit Care Med 2019;200(7):e45–e67.
- Charles PGP, Wolfe R, Whitby M, et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008;47(3):375–384.
- Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax 2019;74(Suppl 1):1–69.
- Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia (CAPE COD). N Engl J Med 2023;388(21):1931–1941.
- Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50(2):1602426.
- Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2022;43(6):687–713.
- Yang M, Yan Y, Yin X, et al. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev 2013;(2):CD006338.
- Mundy LM, Leet TL, Darst K, Schnitzler MA, Dunagan WC. Early mobilization of patients hospitalized with community-acquired pneumonia. Chest 2003;124(3):883–889.
- José A, Dal Corso S. Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial. J Physiother 2016;62(2):96–102.
- Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery (LIPPSMAck-POP): pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
More than one of our services applies here, and which combination suits you depends on what your assessment shows.
- Physiotherapy Assessment — your symptoms, breathing, exercise tolerance and daily function measured properly first
- Airway Clearance Therapy — technique selection and coaching for a wet, difficult-to-clear chest
- Cardiorespiratory Rehabilitation — supervised exercise, breathing technique and self-management education
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Pneumonia is the clearest example of a condition where traditional chest physiotherapy has been tested and found not to work, while mobilisation has been tested and does. The Cochrane review of chest physiotherapy in adult pneumonia found no improvement in mortality or cure rate for conventional techniques, positive expiratory pressure or osteopathic manipulation; early mobilisation shortens hospital stay.1,2 Consolidated lung does not contain mobile secretions, which is the mechanistic reason those trials are negative.
Medical management that shapes the session
- Severity assessment drives site of care — CURB-65 internationally and SMART-COP in Australia, the latter designed to predict need for intensive respiratory or vasopressor support.3,4
- Hydrocortisone reduced mortality in severe community-acquired pneumonia in CAPE COD, the most significant change in CAP management in a decade.5
- Guideline antibiotic therapy with early administration and de-escalation on clinical response remains the determinant of outcome; failure to improve at 48–72 hours should prompt review for complication rather than more physiotherapy.3
- Vaccination against pneumococcus and influenza reduces incidence and severity, and is legitimate to check in a physiotherapy consultation.3
What physiotherapy achieves
- Early mobilisation shortens length of stay without increasing adverse events — the strongest positive evidence in this population.2
- Structured inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life compared with usual care.6
- Airway clearance is indicated only for demonstrable sputum retention — a coexisting bronchiectasis, cystic fibrosis or COPD exacerbation, a weak or absent cough from neuromuscular disease, or post-operative retention.1,7
- Positioning affects oxygenation in unilateral disease, and non-invasive ventilation has a role in selected hypoxaemic or hypercapnic patients, though the evidence in pneumonia alone is weaker than in COPD or cardiogenic pulmonary oedema.8
- Prevention of hospital-acquired pneumonia is a physiotherapy-adjacent bundle: head-of-bed elevation, oral care, early mobilisation, and postoperative lung-expansion therapy in at-risk patients.9,10
- Recovery is longer than most patients expect, with fatigue and reduced exercise capacity persisting for weeks to months and cardiovascular risk transiently elevated after the episode.6
Physiotherapy implications
- Do not treat consolidation with percussion and vibration. If there is no sputum to move, the treatment has no target and costs the patient energy.1
- Mobilise from day one: sitting out of bed, standing, short walks, progressed daily and documented — this is the intervention with the evidence.2
- Use positioning as therapy: upright, and in unilateral pneumonia test the good-lung-dependent position with oximetry to confirm benefit in that individual.
- Screen for the genuine clearance indications — chronic suppurative disease, weak cough, neuromuscular weakness, postoperative state — and treat those patients properly rather than treating everyone.7
- Prioritise the frail older patient's function: for them the dominant problem is delirium and decline, not gas exchange, and mobility is the whole treatment.
- Escalate rising oxygen requirement, respiratory rate over 30, exhaustion with a falling rate, confusion, hypotension, or failure to improve at 48–72 hours (consider empyema, abscess, resistant organism or wrong diagnosis).
- Refer onward at discharge and set recovery expectations, using objective measures such as walking distance and sit-to-stand to show progress.6
Clinical reasoning
- Crackles in pneumonia usually mean consolidation, not retained sputum — the auscultation finding is not itself an indication to treat.
- Ask what the actual problem is: oxygenation (position, oxygen), ventilatory failure (escalate), retained secretions (clear), or deconditioning (mobilise). Most inpatients need the last.
- Aspiration risk — stroke, dysphagia, reflux, sedation, alcohol — changes prevention and positioning, and should be actively looked for in recurrent pneumonia.
- Recurrent pneumonia in the same lobe warrants imaging for obstruction or bronchiectasis rather than repeated courses of treatment.
Evidence gaps
- Trials of chest physiotherapy in pneumonia are old, small and heterogeneous; the negative conclusion is robust but the subgroups who may benefit have not been defined.1
- Optimal timing, intensity and duration of mobilisation are not established.2
- Post-discharge rehabilitation after pneumonia is under-studied despite documented prolonged functional deficit.6
- The role of non-invasive ventilation in pneumonia without underlying COPD remains uncertain.8
References for the clinical evidence summary
- Yang M, Yan Y, Yin X, et al. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev 2013;(2):CD006338.
- Mundy LM, Leet TL, Darst K, Schnitzler MA, Dunagan WC. Early mobilization of patients hospitalized with community-acquired pneumonia. Chest 2003;124(3):883–889.
- Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official ATS/IDSA clinical practice guideline. Am J Respir Crit Care Med 2019;200(7):e45–e67.
- Charles PGP, Wolfe R, Whitby M, et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008;47(3):375–384.
- Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia (CAPE COD). N Engl J Med 2023;388(21):1931–1941.
- José A, Dal Corso S. Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial. J Physiother 2016;62(2):96–102.
- Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society guideline for bronchiectasis in adults. Thorax 2019;74(Suppl 1):1–69.
- Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J 2017;50(2):1602426.
- Klompas M, Branson R, Cawcutt K, et al. Strategies to prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol 2022;43(6):687–713.
- Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery (LIPPSMAck-POP): pragmatic, double blinded, multicentre randomised controlled trial. BMJ 2018;360:j5916.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.