lower respiratory tract infections in children

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Mostafavi SN. MDPediatric infectious disease

departementIsfahan University of Medical Science

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Lower respiratory tract infectionsPneumonia:

– Viral– Bacterial– Afebrile– Atypical– Aspiration– Nosocomial

Bronchiolitis Empyema

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Case 1A 6 months old boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis?

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Diagnosis of pneumoniaWhat's suggestive symptoms and signs of pneumonia?

Which patient has definite diagnosis of pneumonia?

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Symptoms/signs of pneumoniaAll respiratory infections: fever, cough, Lower respiratory involvement:

respiratory distress, tachypnea, cyanosis

Pneumonia: fine rales, decreasing breath sounds, bronchophonia, …

Definite: new pulmonary infiltration in CXR

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Case 1-1A 6 months old

boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis?

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Case 1-2A 6 months old

boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. What’s your diagnosis?

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Case 1-2Has the infant need admission?

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Admission criteria in pneumoniaInability to intake fluid or

medicationsCyanosis( o2 sat< 92%)Severe respiratory distress( apnea,

…)Toxic appearancePleural effusionSometimes < 1 year18/10/1390 10

Case 1-2Has the patient need antibiotic?

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Type of pneumonia

Viral bacterial

History Age< 5, gradual onset, mild fever, cough, respiratory distress

Abrupt onset, high fever, severe cough, significant respiratory distress

Physical exam

Bilateral rales, high pitched breath sounds,

Focal rales

X ray infiltrates

Bilateral interstitial , peribronchiolar, parenchymal, hyperinflation

Lobar, lobular consolidation , dense parenchymal

ESR, CRP, WBC, PMN

NL to mild increase

Significant increase18/10/1390 12

Case 1-3A 6 months old

boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. If he need any antibiotic?

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Case 1-2A 6 months old

boy brought with high fever and cough. On physical exam tachypnea and bilateral coarse rales were found. If he need any antibiotic?

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Which antibiotic should be prescribed for the infant?

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Microorganism

Outpatient Inpatient

S. pneumonia High dose amoxicillin( 85%), macrolides(60-80%)

High dose penicilline(85%), high dose ampicilline( 85%), Ceftriaxone( > 95%), ceftriaxon+ vancomycine( 100%)

H. Inluenza ( < 5 yr)

Low dose amoxicillin( 50%), low dose co Amoxiclav (>95%), macrolids(> 90%)

Low dose ampicillin(50%), ceftriaxone( 100%)

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Case 1-2What's the clinical course of the patient?

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Clinical course of bacterial pneumoniaImprove in fever and respiratory signs in 48-72 hours

Clearing CXR in 4-8 weeks

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Case 2A 7 years old girl

brought with high fever, malaise, protracted cough, mild diarrhea since 5 days ago. On PE she had bilateral fine rales without significant respiratory distress. She received coamoxiclave since 72 hour ago. Whats your diagnosis?

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Atypical pneumoniaWhat's the suggestive symptoms and signs of atypical pneumonia?

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Atypical pneumoniaAge 5-15 yrSevere constitutional signs: high fever, prolonged

fever, anorexia, malaiseMild respiratory signs: coryza, protracted

prolonged cough, no/mild distress, bilateral mild rales

Prominent extrapulmonary signs: rash, diarrhea, abdominal pain, CNS, …

Prominent x ray abnormalities: bilateral interstitial, lobar infiltrates specially in lower lobes

No response to beta-lactams and dramatic response to azithromycine, clarithromycine, erythromycine

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Case 3A 2 month old boy brought with severe cogh since two days ago and coryza and mild cough since five days ago. His mother has signs of URTI since 7 days ago. On PE RR=70/min, mild cyanosis and diffuse wheezing were found. What's your diagnosis?

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Main clues in bronchiolitisAge:<1 yr ( 2-6 mo), peak admission:

1-3 moEpidemic in Day to Farvardin monthsInitially coryza, cough then severe

cough, wheezing, dyspneaSometimes feverHyperinflation, perihilar infiltration

in x ray18/10/1390 23

Case 3- x ray

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Case 3A 2 month old boy

brought with severe cogh since two days ago and coryza and mild cough since five days ago. His mother has signs of URTI since 7 days ago. On PE RR=70/min, mild cyanosis and diffuse wheezing were found. Has the patient need admission?

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Admission in bronchiolitisO2 saturation< 90-92Age< 6 wkReduced intakeUnderlying heart, lung,

immunological diseaseSevere respiratory distress including

apnea

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What's the outpatient management of bronchiolitis?

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Out patient management of bronchiolitis

No effect of salbutamol, theophylline G, corticosteroids, cough suppressants

Supine position with the head elevatedSmall frequent feedingNose drops and clearingWarning signsMist therapy

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