PNEUMONIA
Saadia Sajjad.Roll no. 460
Learning ObjectivesTo describe the presentation of pediatric
pneumoniaTo outline the management of pediatric
pneumoniaTo summarize the complications of pediatric
pneumoniaTo highlight interventions to prevent and protect
against pediatric pneumonia
What is Pneumonia?
Pneumonia: an inflammation of the lung parenchyma and is associated with consolidation of alveloar spaces.The term “Lower Respiratory Tract Infection” (LRTI) may include pneumonia, bronchiolitis and/or Bronchitis.
Types:
Broncho-PneumoniaLobar Pneumonia.
EpidemiologyPneumonia kills more children under the age of five than any other illness in every region of the world.It is estimated that of the 9 million child deaths in 2007, 20% (1.8 million) were due to pneumoniaApproximately 98% of children who die of pneumonia are in developing countries.
Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
Newborn E.ColiGroup B StreptococciStaph. AureusKlebsiellaPseudomonas
1-3 months Chlamydia trachomatisRespiratory Syncytial virusOther respiratory viruses
3-12 months Respiratory Syncytial virusStaph AureusStreptococcus pneumoniaeHaemophilus influenzaeChlamydia trachomatisMycoplasma pneumoniae
Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory VirusesStreptococcus pneumoniaeHaemophilus influenzaeMycoplasma pneumoniaeChlamydia pneumoniae
5-18 years Mycoplasma pneumoniaeStreptococcus pneumoniaeChlamydia pneumoniaeHaemophilus influenzaeInfluenza viruses A and BAdenovirusesOther respiratory viruses
AgePresence of cough, difficulty breathing, shortness of breath, chest painFeverRecent upper respiratory tract infectionsAssociated symptoms Duration of symptoms Immunizations status
TB exposureMaternal Chlamydia, Group B Strep status during pregnancyChoking episodesPrevious episodesPrevious antibiotics
Pneumonia History
Pneumonia HistoryTravel historyDay care attendanceAnimal exposureIll contacts
Past MedicationsBirth HistoryMedicationsAllergiesImmunization StatusHome EnvironmentSocial HistoryFamily History
Recognition of Signs of Pneumonia
Tachypnea is the most sensitive and specific sign of pneumonia
Age Respiratory Rate(breaths/min)
Indication of severe infection (breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5 years
> 40 >50
Greater than 5 years
> 20
Other signs of pneumonia -Indrawing
out---breathing---in Lower chest wall indrawing: with
inspiration, the lower chest wall moves in
Other signs of pneumonia - Nasal Flare
Nasal flaring: with inspiration, the side of the
nostrils flares outwards
Diagnosis in Community Setting
SIGNS Classify AS Treatment
•Tachypnea•Lower chest wall indrawing•Stridor in a calm child
Severe Pneumonia •Refer urgently to hospital for injectable antibiotics and oxygen if needed•Give first dose of appropriate antibiotic
•Tachypnea Non-Severe Pneumonia
•Prescribe appropriate antibiotic•Advise caregiver of other supportive measure and when to return for a follow-up visit
•Normal respiratory rate Other respiratory illness
•Advise caregiver on other supportive measures and when to return if symptoms persist or worsen
Does this infant child have pneumonia?
The Rational Clinical Exam, Journal of the American Medical Association
Observation of the infant is the most important part of the examination – does the child look sick?
Respiratory rate should be calculated over two thirty second intervals, or one minute due to moment to moment variability.
Auscultation is unreliable when examining infants. In older children, examination will show diminished
movements on affected side, dullness on percusion, bronchial breathing. Moist rales on resolution.
Pneumonia Severity Assessment
Mild Severe
Infants Temperature <38.5 CRR < 50 breaths/minMild recessionTaking full feeds
Temperature >38.5 CRR > 70 breaths/minModerate to severe recessionNasal FlaringCyanosisIntermittent ApneaGrunting RespirationsNot feeding
Older Children Temperature <38.5 CRR < 50 breaths/minMild breathlessnessNo vomiting
Temperature >38.5 CRR > 50 breaths/minSevere difficulty in breathingNasal FlaringCyanosisGrunting RespirationsSigns of dehydration
Indications for Admission - IMCI
All Children with Very Severe Pneumonia need admission
Very Severe Pneumonia includes any of: Cough or difficult breathing plus at least one of the
following: Central cyanosis Inability to breastfeed or drink, or vomiting everything Convulsions, lethargy or unconsciousness Severe respiratory distress (e.g. head nodding) Some or all of the other signs of pneumonia (tachypnea,
grunting, nasal flare, indrawing, changes in auscultation)
Age Group Indications for Admission to Hospital
Infants Oxygen Saturation <= 92%, cyanosisRR > 70 breaths /minDifficulty in breathingIntermittent apnea, gruntingNot feedingFamily not able to provide appropriate observation or supervision
Older Children Oxygen Saturation <= 92%, cyanosisRR > 50 breaths /minDifficulty in breathingGruntingSigns of DehydrationFamily not able to provide appropriate observation or supervision
Indications for Admission
Investigations
Chest X-rayWBC Count
Blood CultureGram Staining of expectorated sputum
Pleural fluid examinationASO titre
Tuberculin skin test
Chest X-ray
Consider if available and: Infection is severe Diagnosis is otherwise inconclusive To exclude other causes of shortness of
breath (e.g.. foreign body, heart failure) To look for complications of pneumonia
unresponsive to treatment (e.g.. empyema, pleural effusion)
To exclude pneumonia in an infant less than three months with fever
Complications of Pneumonia
Pleural effusionEmpyemaParapneumonic effusions Lung abscessPneumothoraxPneumatoceleDelayed ResolutionRespiratory FailureMetastatic Septic lesionsActivation of latent TB
Treatment – IMCI Guidelines
Antibiotic therapyChloramphenicol (25 mg/kg IM or IV every 8 hours) until the child has improved. Then continue orally 3 x/ day for a total course of 10 days. If chloramphenicol is not available, give benzylpenicillin (50 000 units/kg IM or IV every 6 hours) and gentamicin (7.5 mg/kg IM once a day) for 10 days.
If the child does not improve within 48 hours, Switch to gentamicin (7.5 mg/kg IM once a day) and cloxacillin (50 mg/kg IM or IV every 6 hours), for staphylococcal pneumonia.When the child improves, continue cloxacillin (or dicloxacillin) orally 4 times a day for a total course of 3 weeks.
Supportive Treatment – IMCI Guidelines
Oxygen therapyIf fever (=>39oC) causing distress, give paracetamolIf wheeze is present, give a rapid-acting broncho-dilatorGentle suction any thick secretions in the throat, which the child cannot clear.
Ensure that the child receives daily maintenance fluids for the child's age - avoid overhydration. Encourage breastfeeding and oral fluids. If the child cannot drink, insert a NG tube and give maintenance fluids in frequent small amounts. If the child is taking fluids adequately by mouth, do not use a NG tube as it increases the risk of aspiration pneumonia. If oxygen is given by nasopharyngeal catheter at the same time as NG fluids, pass both tubes through the same nostril.Encourage the child to eat as soon as food can be taken.
Prevention Strategies
Vaccination against measles, Streptococcus pneumoniae, and Haemophilus influenzae type bPublic awarenessInterventions to protect against pneumoniaZinc supplementationPrevention of HIV in ChildrenCo-trimoxazole prophylaxis for HIV-infected children
Prevention - Vaccination
Haemophilus Influenzae type B (Hib) vaccine Pneumococcal conjugate vaccinePneumonia is a possible complication of Measles, thus prevention of measles would decrease the incidence of pneumonia.
A Complicated Case from Gambia
Based on a true story
Case – Chief Complaints
A 1 year old child is brought in for fever, cough, lethargy, and mild respiratory distress increasing over 2 weeks.
You take a focused medical history from the child’s mother.
What are the patient’s vital signs?
Vital signs are as follows: Temperature 38.7, Pulse 150, Respiratory Rate 54, Oxygen Saturation 94% on room air.
What is observed on physical examination?
On observation the patient clearly appears septic. Mild respiratory distress is present. Skin is mottled.
What is the likely diagnosis?
What other physical examination information is immediately relevant to forming an initial treatment plan for this patient?
Weight and Hydration Status
The child is malnourished
The patient appears mildly dehydrated.
What interventions should be started?
Initial Treatment
A presumptive diagnosis of pneumonia is made. The patient is admitted to the hospital and started on broad spectrum IV antibiotics and appropriate hydration and re-feeding.
The patient does not seem to improve initially.
What is your differential diagnosis?
Differential Diagnosis includes:
Pneumonia +/- complications (e.g. Empyema)Pneumonia in a patient with HIVTuberculosis
What is the first investigation you would order? (assume first choice investigation is available).
The chest x-ray reveals a right sided lobar infiltrate.
What is the clinical correlation?
The patient begins to improve clinically.Fever, cough and respiratory distress resolve.
However, over the next few weeks of appropriate re-feeding, the patient fails to gain weight despite remaining on broad spectrum antibiotics.
What other investigations would you Consider?
HIV test – negativeTB skin test – unreactiveSputum culture – unable to induce sputum
*Important Note: The mother is no longer with the patient. Another family member reports that she is sick with a cough, fever, and weight loss.*
What other courses of treatment should be considered in this case?
The patient was started on treatment for tuberculosis and began to improve and gain weight.
This patient did well. The mother and other close contacts were also treated for tuberculosis.
This patient’s x-ray revealed a lobar infiltrate.Pneumonia commonly presents as a lobar infiltrate. Reactivation of TB tends to be apical, but acute TB can present as a lobar infiltrate.TB should remain as a differential diagnosis and be reconsidered if there is a poor response to treatment, or a possible exposure history.
Summary
1)What is the most sensitive and specific sign of
pneumonia in children?A. Difficulty breathingB. FeverC. TachypneaD. Tachycardia
2)Which of the following immunizationeffectively reduce pneumonia mortality inchildren?A. Haemophilus influenzae b VaccineB. Pneumococcal Conjugate VaccineC. Measles VaccineD. All of the above
3)Which of the following bacterial pathogens most commonly cause bacterial infections in neonates?
A. E. coli, S. pneumoniae, H. influenzaB. Group B Streptococci, E. coli, L. monocytogenesC. Group B Streptococci, H. influenzae, E. coliD. S. pneumoniae, H. influenzae, N. meningitidesE. S. pneumoniae, N. meningitides, L. monocytogenes
4)Which of the following pneumonia-causing pathogens is the most common cause of pneumonia in immunized children?
A. Bordetella pertussisB. Group A streptococcusC. Haemophilus influenzae type BD. InfluenzaE. Streptococcus pneumoniae
5) Which organism is NOT likely to cause pneumonia with parapneumonic effusion or empyema?
A. Group A streptococcusB. Mycoplasma pneumoniaeC. Staphylococcus aureusD. Streptococcus pneumonia
6)Which organism is the most likely organism to cause pneumonia in a 2 year old child? A. InfluenzaB. MetapneumovirusC. Mycoplasma pneumoniaeD. Streptococcus pneumoniaeE. Respiratory syncytial virus
7) Which combination of signs and symptoms is typical of community acquired pneumonia?
A. Clear lung exam, fever, coughB. Crackles, normal respiratory rate, coughC. Tachypnea, cough, feverD. Tachypnea, vomiting and rashE. Wheezes, retractions, nasal flaring
8)Which patient would be the most likely to have bacterial Pneumonia?
A. 1 year old boy with 1 day history of low grade fever, barky cough, RR of 30 in OctoberB. 3 year old male with 3 day history of fever, rhinorrhea, and faint rash in MayC. 4 year old male with 5 day history of fever, cough, retractions and fatigue in FebruaryD. 5 year old female with asthma, and now 1-2 day history of fever and wheezing in MarchE. 8 year old female with 3 day history of fever, cough, sore throat and myalgias in January